Control
Independent Audit and Verification
Independent examination, audit and verification of safety arrangements.
Newest 100 Documents
All 146 in search- 202631 Mar
Ageing assets and life extension
Guidance on managing ageing assets and extending facility life through lifecycle planning, performance monitoring and integrity assurance. It presents a plan-do-check-act self-assessment framework, ageing modes analysis, competence arrangements and independent verification. Regulatory duties and health and safety representative involvement are discussed, alongside a Northern Endeavour corrosion example.
- 202631 Mar
Hazard identification and risk assessment guidance note
Guidance for titleholders on assessing well integrity risks throughout the well lifecycle. It discusses subsurface assessment, independent design review, qualitative and quantitative analysis, FMECA, bow-tie methods and risk registers. Risk profiles inform monitoring and maintenance regimes, anomaly management, change assessment, and planning for well suspension and abandonment.
- 202624 Mar
MAIB: Sinking of tug Biter with loss of two lives
This safety flash summarises MAIB findings on Biter’s fatal girting and capsize during passenger-vessel towage off Greenock. It highlights incomplete operational exchanges, inadequate pilot training, speed-related line loading, ineffective gob-rope protection and an open hatch. Recommendations address risk assessments, gob-rope rigging, manoeuvring speeds and tug-master and pilot training.
- 202524 Sep
Validation Guideline
Guidance explains NOPSEMA’s validation requirements for proposed facilities and significant changes. It addresses agreement of scope, selection of safety-critical technical systems, validator independence and competence, and written deliverables. Validation is linked to safety-case acceptance, distinguished from verification, and illustrated through diving-system and well-testing applications.
- 202517 Sep
SWL plate dropped from crane block
A safety flash describes a 0.9 kg SWL plate falling from an auxiliary hook block onto a vessel’s main deck, with its fall height unconfirmed. Suspected galvanic corrosion caused rivet failure. It highlights missed inspection hazards, undocumented fittings, checks of other plates and a brought-forward third-party DROPS inspection.
- 2025Sep
1 - Big people in lifeboats and lifesaving appliances
Guidance for offshore dutyholders on accommodating increasing worker weight and size in evacuation and rescue arrangements. It explains statistical passenger design-weight calculations, capacity adjustments, seating and restraint suitability, and considerations for other lifesaving appliances and medical equipment. It also addresses verification, interim arrangements and safety-case changes.
- 2025Jul
Hydrocarbon Active Fire Protection
An inspection guide for offshore hydrocarbon fire protection, setting out regulatory expectations, success criteria and dutyholder scoring. It examines firewater pumps, ring mains, deluge coverage and chemical dosing, with emphasis on corrosion, marine growth, system availability, as-found testing and investigation of recurring blockages.
- 202512 Jun
Design notification guidance note
Explains design notification requirements for new or significantly altered production facilities and new greenhouse gas facilities. Covers notification triggers, design options, major accident risks, pipeline materials, decommissioning and site conditions. Clarifies independent validation, subsequent safety-case demonstrations and NOPSEMA’s assessment process, which produces written comments rather than acceptance.
- 202527 May
Honeywell Geismar Chlorine and Hydrogen Fluoride Releases
Investigation of three releases at Honeywell Geismar’s HFC-245fa unit between 2021 and 2024, involving fatal HF exposure, a corrosion-driven reboiler explosion and serious injury during gasket replacement. The report examines mechanical integrity, startup procedures, protective equipment, organisational change and capital funding, recommending independent auditing and safer-technologies analysis.
- 202522 May
EC175 B Rotor Blade Failures at Offshore Platform During Strong Winds
Investigates rotor blade failures on EC175 B G-MCSH at the Elgin platform during strong winds. A partially seized rotor brake prevented blade securing; local vertical airflow was considered to exacerbate blade sailing. The report examines maintenance, securing equipment, helideck airflow, wind reporting and flight recorder anomalies, and makes six safety recommendations.
- 202524 Apr
Person overboard from keelboat LimbItless with loss of 1 life
This investigation examines Elizabeth Wood’s fatal fall overboard from LimbItless off Cowes. The precise fall mechanism remains unknown. It analyses inadequate individual recovery planning, volunteer training, lifejacket suitability and absent safety-boat support, alongside gaps in oversight of charitable sailing activities and subsequent improvements to recovery provision.
- 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.
- 2025Feb
Process safety leadership findings of Energy Division inspection programme
HSE reports findings from inspections of UKCS production operators’ process safety leadership, using a consistent framework based on the COMAH leadership intervention tool. It examines leadership competence, contractor assurance, cumulative risk, performance indicators and incident learning, identifying weaknesses alongside good practice and recommendations for duty holders.
- 2025
2 - Integrity management of FPSOs/FSUs
OMAR guidance addresses structural and maritime integrity of UKCS FPSOs and FSUs, drawing on regulatory interventions. It discusses inspection regimes, hull loading, watertight integrity, cargo systems and station keeping, alongside competence, independent verification and safety-case review. Ageing assets and formal life-extension assessments receive particular attention.
- 202417 Oct
Financial assurance for petroleum titles guideline
Guidance explains petroleum titleholders’ ongoing financial assurance duties for costs and liabilities arising from petroleum escapes. It covers robust cost estimation, independent validation and endorsement of methods, accessible assurance arrangements, environment-plan submissions and regular review. Assurance does not cap liability, and registered titleholders retain individual responsibility for compliance.
- 202422 May
Grounding of roll-on/roll-off passenger ferry Alfred
Investigation of Alfred’s grounding at Swona Island on 5 July 2022, which injured 41 people. The master almost certainly fell asleep while steering close inshore. Analysis examines passage planning, ECDIS use, bridge staffing, fatigue management, emergency response and vehicle securing, alongside shortcomings in audits and surveys.
- 202419 Apr
Renewable Energy Modernization Rule
Unofficial prepublication final rule modernising US offshore renewable energy regulation. It addresses leasing, meteorological buoy approvals, deferred geotechnical investigations and financial assurance, alongside independent project verification, commissioning, inspections and safety management reporting. Agency responses explain adopted changes, rejected proposals and continuing environmental review obligations.
- 202416 Apr
Main bell wire rope damaged
During bell recovery after a saturation dive, a broken outer wire rope strand lifted a proximity switch bracket into the sheave, damaging the main bell wire. Operators stopped recovery and freed the bracket. The flash describes design shortcomings, sensor relocation, cutting back damaged wire, a witnessed load test and an empty-bell trial.
- 20241 Apr
Functional Safety Inspection Guide
Inspection guidance for assessing dutyholders’ management of functional safety against BS EN 61511. It covers lifecycle assessments, competence, SIL allocation and verification, safety requirements, commissioning, proof testing, maintenance and modifications. The Functional Safety Assessment Framework links compliance gaps to performance scores and initial enforcement expectations.
- 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.
- 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.
- 202324 Aug
Safety warning issued about servicing and certification after a liferaft failed to inflate during an emergency
MAIB reports liferaft servicing and certification deficiencies identified after Piedras foundered and its port liferaft failed to inflate correctly. Examination of the recovered starboard raft and further inspections revealed expired supplies and neglected components. The bulletin recommends urgent reinspection and servicing of affected DSB liferafts certified by Comfer Marin SL.
- 202321 Jun
Sheave became detached during lifting operations
A sheave detached during recovery of marine geophysical sensors and fell approximately 6 m to the deck, with nobody underneath. The flash identifies installation, change-management and verification shortcomings, including removed secondary retention. Actions included replacing the swivel connection, adding securing arrangements and improving equipment records and written instructions.
- 20239 Feb
High-potential near miss: Uncontrollable movement of auxiliary whip line
A vessel crane near miss involved uncontrolled auxiliary-line movement during start-up following water damage to its encoder. The wire parted, ejecting the block and hook before they fell to the deck; nobody was harmed. Lessons address encoder replacement, crane inspection, hook storage and revised procedures, risk assessments and personnel barriers.
- 2023
Ren Split Rule 2023
Unofficial pre-publication text of a joint final rule transferring offshore renewable-energy safety, environmental oversight and enforcement regulations from BOEM to BSEE without changing substantive requirements. It sets out revised regulatory parts, agency responsibilities, facility verification, inspections, environmental reviews, reporting and decommissioning provisions, including alternate uses of existing facilities.
- 202213 Dec
Near miss: pipe dropped from pipe supports
A pipe fell from temporary easels while a worker turned it during cleaning with an angle grinder and abrasive sanding wheel. No injury or damage occurred. The flash identifies inadequate supports and gaps in manual-handling risk assessment, recommending mechanical turning devices, stronger contractor oversight and verification of third-party operations.
- 2022Dec
CHIRP Maritime FEEDBACK 69
This maritime digest examines unsafe pilot boarding arrangements, helm execution, substandard ship conditions, collision avoidance, a crushed mooring launch and yacht grounding. Commentary emphasises closed-loop communication, challenging unsafe directions and port coordination. A separate article explores links between fishing crews’ working conditions, labour exploitation and safety.
- 20221 Nov
Focus on third-party dropped objects
This safety flash reports increased dropped-object incidents at third-party premises, including high-potential near misses during lifting and pipe handling. Findings concern procedural controls, risk assessment, equipment suitability, competence, inspection and maintenance. Recommendations emphasise contractor assurance, clear accountabilities, verification of controls, fresh-eyes reviews and communicated stop-work expectations.
- 202229 Jul
Loy Lange Box Company Pressure Vessel Explosion
Investigation of a fatal steam-system pressure vessel explosion in St. Louis examines oxygen corrosion, incomplete repairs, water treatment and inspection failures. Metallurgical examination and thickness measurements underpin the findings. The report analyses regulatory oversight and process safety management, while noting that the pressure at rupture could not be determined.
- 20228 Jun
Human Factors information paper - Risk migration
Explains how operational trade-offs can gradually erode safety margins, using a well abandonment campaign involving offshore hydrocarbon gas venting. Examines deficient hazard assessment, equipment assurance and modification controls through systems theory, distinguishing possible explanations from verified findings. Introduces guided adaptability to support anticipation, coordinated responses and proactive learning.
- 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.
- 202131 Aug
What are audits for? Some eCMID findings
This safety flash reviews findings from 769 eCMID vessel inspections over the 12 months to April 2021. It highlights shortcomings in confined-space entry arrangements, chemical handling procedures, firefighting equipment, watertight closures, navigation equipment, engine-room practices and lifting-equipment management, alongside links to related incidents.
- 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.
- 202130 Mar
Incorrect measurement and markings on divers umbilical
A diving operation was stopped after umbilical distance markings were found to use incorrect colours and a wrong measurement datum. Nobody was harmed, but checking and remarking caused lost time. The flash addresses unclear checking responsibilities, refresher training, mobilisation checks and audit comparison using a 50 m tape.
- 202125 Feb
Engine failure and subsequent fire on ro-ro cargo vessel Finlandia Seaways with 1 person injured
Investigation annexes examine a vessel’s main-engine failure and engine-room fire through connecting-rod fracture analysis, microscopy and material testing. Fatigue was identified, but consequential damage limited precise initiation-site identification. Supporting documents address connecting-rod ovality, recommended replacement intervals and machinery survey examinations credited through Chief Engineers.
- 202128 Jan
The Offshore Audit, Monitoring and Review Inspection Guide
An offshore inspection guide for assessing duty holders’ audit, monitoring and review arrangements for major accident hazards. Templates examine assurance planning, auditor independence, competence, barrier coverage, report quality and closure of findings. It also addresses performance evaluation, organisational learning, regulatory success criteria and inspector judgement when assigning overall scores.
- 202119 Jan
Wells Personnel Competency Management System – Issue 6
An HSE inspection guide for assessing wells personnel competence management systems. It sets performance criteria and interview, record-sampling and scoring frameworks, covering individual and team assessment, contractor assurance, assessor training and external audit. Discussion includes non-technical skills, well-control drills and simulation-based training for challenging wells.
- 2021Jan
Structural integrity requirements for the decommissioning and dismantlement of fixed offshore installations
Guidance for duty holders on maintaining structural integrity during fixed offshore installation decommissioning and dismantling. It addresses unattended lighthouse mode, re-boarding, strength, lift and stability assessments, structural modifications and final removal. It also explains verification arrangements and differing safety-case expectations for small installation campaigns and larger, more complex dismantling projects.
- 2021
Asbestos - The Analysts' Guide
Guidance for asbestos analysts covering representative bulk and airborne sampling, microscopy, analytical quality assurance and independent four-stage clearance certification. It distinguishes fibre counting from asbestos identification and personal exposure from clearance results. Additional procedures address contaminated soils and made ground, respiratory protection, protective clothing, decontamination and analyst competence.
- 202027 Nov
Blind Shear Rams Damaged after Inadvertently Closing on Tool String
During completion operations in the Gulf of Mexico, blind shear rams struck a test tool after drill pipe inadvertently backed off while releasing it. The alert describes equipment damage and delayed reporting, and recommends considering prompt notification, stack inspection, verification of test conditions and compliance with independent third-party requirements.
- 202013 Jul
MOB fatality: Person fell between vessel and jetty
This flash summarises MAIB findings on the fatal crushing of Cherry Sand’s Master during self-mooring at Rosyth. He attempted to step ashore before the dredger was alongside. It highlights hazardous transfer practices, absent linesmen and audit shortcomings, alongside recommendations concerning self-mooring guidance and fleetwide procedures.
- 202021 May
Assurance of TEMPSC and associated systems guideline
NOPSEMA outlines expectations for assuring totally enclosed motor propelled survival craft at offshore petroleum facilities. The guideline addresses inspection, maintenance, waterborne testing and workforce competence, including hull integrity, buoyancy, deluge, propulsion and steering performance. It discusses limitations of alternative MODU drill arrangements and considers annual testing adequate for specified systems.
- 202021 May
Competency assurance information paper
This information paper explains how organisations can define, develop, verify and maintain workforce competencies for hazardous-event prevention and mitigation. It discusses supplementary field learning, evidence-based assessment, contractor assurance and change-triggered reviews. A hypothetical lifting example illustrates implementation, while emphasising that competency assurance cannot replace organisational support or other safeguards.
- 202021 May
Personnel resourcing information paper
This information paper examines how personnel resourcing affects human reliability, particularly through fatigue and time pressure. It discusses emergency response staffing, maintenance scheduling and independent checks, and supervisory workload. Drawing on SPAR-H, it outlines approaches organisations may consider to reduce error and support effective risk management.
- 20207 May
Common Operator Deficiencies Discovered by SEMS
BSEE summarises common SEMS audit deficiencies across 41 operators during November 2016–November 2019. Findings address management of change, procedure reviews, training assurance, mechanical integrity and documentation. Operators and contractors are encouraged to consider reviewing programme gaps, implementing corrective actions, sharing updates, revising bridging documents and seeking workforce feedback.
- 202017 Mar
Damage and engine room flooding following contact by tugboat
A tug lost manoeuvrability during berthing and struck a vessel, tearing its hull and flooding the engine room. Emergency bilge suction using a ballast pump controlled the flooding. The flash examines excessive vessel speed, rough weather, communication and supervision failures, and stresses the master’s authority and familiarity with damage-control arrangements.
- 20202 Mar
SECE Management and Verification - Version 2 March 2020
An inspection guide for assessing safety and environmental critical element management and verification on offshore installations. It examines barrier identification, performance standards, competence, change management and independent assurance. Detailed criteria address examination sampling, findings closure, scheme reviews, and interfaces with well examination and classification arrangements.
- 201917 Jul
Collision between rigid inflatable boat Tiger One and a mooring buoy with 4 people injured
Investigation of Tiger One’s night-time collision with a River Thames mooring buoy, injuring two crew and two passengers. It examines buoy-light visibility, navigation by eye, limited local night experience, chart-plotter use and protective seating and kill-cord arrangements. Subsequent actions addressed night-time speed limits, passenger reporting and independent safety-management audits.
- 201911 Jul
EC175B Nose Landing Gear Collapsed on Landing
An EC175B helicopter’s nose landing gear collapsed on landing at Aberdeen Airport after a pintle pin failed. Investigation found that a bushing had been omitted during A-frame replacement. The report examines maintenance instructions, independent inspection, staffing and fatigue, and describes procedural changes and manufacturer inspection requirements.
- 2019Jul
Structural Integrity Management
Guidance sets out a lifecycle framework for managing offshore structural integrity against UK regulatory requirements and industry standards. It covers policy, responsibilities, inspection planning, structural reassessment, maintenance, information retention and audit. Competence, independent verification, emergency preparedness and gap analysis support implementation, with attention to ageing installations and life extension.
- 201925 Jun
DuPont La Porte Facility Toxic Chemical Release
Investigation of a fatal methyl mercaptan release at DuPont’s La Porte insecticide unit. Four workers died inside the manufacturing building. The report examines hydrate-blocked pipework, drain valves, inadequate safeguards, alarm communication and emergency response, alongside management of change, audit effectiveness, process safety culture and misleading reliance on occupational injury metrics.
- 2019
Proposed Well Control Rule Revisions Fact Sheet
Technical fact sheet summarising BSEE’s final revisions to well-control regulations for offshore oil and gas operations. It explains changes to real-time monitoring, independent verification, accumulator requirements and alternating BOP testing schedules, alongside retained provisions for double shear rams, maintenance, ROV intervention and source control.
- 201817 Dec
Quality assurance of diving system audits
NOPSEMA highlights shortcomings in diving-system audits, including missed wire deterioration, damaged oxygen hose and inadequate hyperbaric evacuation arrangements. The alert calls for quality assurance of audits, competent auditors and reviewers, and verified closure of safety-critical non-conformances before diving begins. It also discusses relevant statutory duties.
- 201817 Jul
Safety case approvals
Explains NOPSEMA’s offshore petroleum safety-case approval process, including operator responsibilities, independent validation, assessment decisions and ongoing compliance oversight. Describes safety-case contents, risk reduction to ALARP, revision triggers and mandatory workforce consultation, alongside the role of health and safety representatives in workforce participation.
- 201715 Nov
USCG: Remain upright by fully understanding vessel stability
This flash summarises US Coast Guard stability guidance following a fatal fishing-vessel casualty in the Bering Sea, with investigation still incomplete. It emphasises understanding Stability Instructions, developing crew knowledge, comparing instructions with actual loading, and independent review. It also highlights conversion-related accuracy and icing risks.
- 20171 Oct
Well Examination Scheme - Issue 4
Inspection guidance for assessing well operators’ examination schemes across the well life cycle. It addresses documentary assurance, examiner independence and competence, management of changes, barrier verification and interfaces with installation verification. Interview material and success criteria support consistent recording of findings, compliance scoring and regulatory intervention planning.
- 20176 Sep
Grounding of semi-submersible rig Transocean Winner after the loss of tow from tug ALP Forward
Investigation of Transocean Winner’s grounding off the Isle of Lewis after loss of tow from ALP Forward. Analysis examines weather-driven loss of control, deteriorated wire rope, catenary and shock loading, missing windage information, passage planning and emergency towing limitations. Recommendations address towing procedures, reporting and tow-line maintenance.
- 20179 Jun
Near-miss: Broken chain on self-propelled hyperbaric lifeboat (SPHL) recovery rigging
A hyperbaric lifeboat’s aft lifting chain failed during transfer from davits to a crane for a reception-facility mating trial. Nobody was injured. External storage contributed to corrosion, while a protective cover concealed damage from inspection. Actions included destroying chain slings older than 12 months, below-deck storage and auditing third-party inspection compliance.
- 20173 Mar
Clarification from NOPSEMA: Quality assurance of diving system audits
This flash relays NOPSEMA’s revised alert on inadequate diving-system audits. It identifies deficiencies in man-riding wire certification and test deferral, emergency umbilical availability, oxygen-hose condition and practicable upgrades to older systems. It stresses that audits should identify and rectify deficiencies affecting system integrity and emergency functionality.
- 201628 Jun
Environmental Assessment
Final environmental assessment comparing regulatory alternatives for exploratory drilling in the Beaufort and Chukchi seas. It evaluates direct, indirect and cumulative effects of drilling-waste capture, well monitoring, source control, relief rigs and spill preparedness, balancing potential environmental benefits against additional operational disturbance and risks associated with more frequent BOP testing.
- 2016Jun
Regulatory Impact Analysis
Final regulatory impact analysis assesses Arctic offshore exploratory drilling requirements through a ten-year numbered scenario. It distinguishes baseline and incremental compliance costs, applies two discount rates, and evaluates potential avoided spill consequences. Substantive measures include source-control equipment, relief rigs, operational planning, testing, training and audits; benefit estimates retain substantial uncertainty.
- 201620 Apr
Capsize and sinking of cement carrier Cemfjord with loss of 8 lives
Investigation of Cemfjord’s rapid capsize in the Pentland Firth and subsequent sinking, with eight crew assumed lost. AIS, radar, environmental modelling and underwater surveys inform analysis of violent seas, passage planning, cargo stability and probable fatigue. The report also examines rescue-boat incompatibility, bilge pumping deficiencies and ineffective regulatory assurance.
- 20164 Feb
Collapse of a mezzanine deck on board ro-ro passenger ferry St Helen
Investigation of St Helen’s partial mezzanine car-deck collapse at Fishbourne ferry terminal. A steel wire ramping rope parted during lowering, following excessive wear associated with inadequate lubrication. The report examines rope and sheave condition, consequential beam damage, maintenance management, thorough examinations and unresolved greasing non-conformities.
- 20167 Jan
Injuries due to failure of diver's emergency gas cylinder – use of incompatible threads
Five divers were injured aboard a diving support vessel when a pillar valve detached from an emergency gas cylinder during dive preparation. Preliminary assessment identified incompatible cylinder and valve threads. The flash suggests compatibility checks, permanent identification, separate registration, work instructions and inspection audit records while investigation continues.
- 2015Dec
The Offshore Installations (Offshore Safety Directive) (Safety Case etc) Regulations 2015. Guidance on Regulations
HSE guidance explains the offshore safety-case regime for oil and gas installations in external waters. It covers submissions, acceptance, notifications, lifecycle reviews and transitional arrangements, alongside independent verification and well examination. Detailed guidance addresses major-accident risk evaluation, environmental protection, management systems, combined operations and emergency arrangements.
- 201528 Aug
Thermal tunnel buoyancy when deployed subsea
A thermal tunnel failed to sink during subsea construction because the manufacturer’s buoyancy calculations were incorrect. Additional weight enabled installation beneath a concrete mattress. The flash discusses wet testing, independent buoyancy verification and management of change, while identifying a potential recurrence if the mattress were removed and weight fixings had deteriorated.
- 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.
- 201520 May
Collision between dredger Shoreway and yacht Orca resulting in the yacht sinking with loss of 1 life
Investigation of a fatal collision between dredger Shoreway and yacht Orca off Felixstowe. It examines unattended and lone watches, a bridge blind sector, unused radar information and inadequate vessel-specific procedures. The report also analyses rapid sinking, cabin escape, rescue and automatic lifejacket performance, including an incorrectly fitted inflation cylinder.
- 201418 Dec
Injuries due to failure of diver’s emergency gas cylinder
Five divers preparing for a dive aboard a diving support vessel were injured when a valve parted from an emergency air cylinder filled to 180 bar. Preliminary assessment identified incompatible cylinder and valve threads. The flash recommends compatibility checks, traceable identification, working procedures and inspection audit assurance.
- 2014Nov
Grounding of liquefied gas carrier Navigator Scorpio
Investigation of Navigator Scorpio’s grounding on Haisborough Sand on 3 January 2014. It examines incomplete passage planning, distraction during chart corrections, inadequate position monitoring, wind and tidal effects, insufficient bridge manning and ineffective audit follow-up. The vessel refloated undamaged, with no injuries or pollution; management subsequently strengthened training and navigation guidance.
- 2014Oct
guide to the health and safety regulatory regime
Guidance for planners explains HSE’s regulation of shale gas wells and its relationship with planning authorities and environmental regulators. It describes lifecycle well integrity, steel casing and cement, abandonment plugs, advance notifications, weekly reporting and independent well examination, alongside hydraulic fracturing consent requirements and routes for raising site concerns.
- 201417 Jul
Bell re-claim failure resulting in minor injury
A saturation-diving incident at 110 msw injured a bellman when a reclaim-line water trap ruptured. An inverted check valve allowed retained exhaust gas to pressurise the trap following a compressor solenoid failure. The flash examines refurbishment errors, filter-change maintenance and inspections that missed the incorrectly fitted component.
- 2014Jul
Crush incident between containers on deck of ro-ro cargo vessel Tyrusland with loss of 1 life
Investigation of a fatal container-crushing accident during discharge aboard Tyrusland, berthed in Tripoli. It examines forklift manoeuvres, twistlock removal, closed-corner trailers and failures in signalling and briefing. The report identifies an unsafe system of work, deficient risk assessments and weaknesses in safety-management audit follow-up; no new recommendations were made.
- 2014Jul
Fire in accommodation area on general cargo vessel Celtic Carrier with 1 person injured
Investigation of Celtic Carrier’s accommodation fire off Cape Trafalgar examines cigarette ignition of sofa foam, crew escape and firefighting, including breathing-air limitations and boundary cooling. It identifies inadequate emergency preparedness, falsified drill records and weaknesses in company safety culture and regulatory auditing, and records subsequent corrective actions.
- 20145 Jun
Macondo Volume 2 Final Report
Volume 2 examines the Deepwater Horizon blowout preventer’s failure to seal the Macondo well, including off-centre drillpipe buckling, miswired solenoid valves and emergency-system assurance gaps. It uses forensic testing and modelling to assess barrier performance, comparing regulatory approaches and recommending lifecycle management and independent verification of safety-critical elements.
- 2014Jun
Person overboard from motor tug Endurance while crossing to unmanned motor cruiser Sirius M with loss of 1 life
Investigates a fatal fall into the sea during an attempted transfer from Endurance to unmanned cruiser Sirius M after towline failure. Examines towline chafe, towing practice, unsuccessful recovery, flotation protection, likely fatigue effects and qualification deficiencies, alongside shortcomings in vessel surveys, certification scrutiny and port oversight.
- 2014May
Key Programme 4 (KP4) Report
HSE reports findings from its 2011–2013 ageing and life-extension inspection programme for offshore installations. It examines structural, process, marine and pipeline integrity, equipment obsolescence and organisational arrangements. Recommendations emphasise forward planning, performance-data trending and assurance, supported by dutyholder case studies covering structural monitoring, gap analysis and hydrocarbon leak reduction.
- 2014Apr
Grounding of general cargo vessel Danio
Investigation of Danio’s grounding off Longstone on 16 March 2013 after its lone bridge watchkeeper fell asleep. The report examines cumulative fatigue, falsified rest records, absent lookouts, a disabled watch alarm and over-reliance on electronic charts. It addresses safe manning and auditing of actual onboard practice; no pollution occurred.
- 2014
Safe use of lifting equipment
Approved Code of Practice and guidance explaining LOLER duties for work equipment. It addresses equipment selection, strength, stability, personnel lifting, positioning and safe working load markings. Lift planning, supervision and competence are covered alongside thorough examination, inspection, defect reporting and retention of examination records.
- 2013Jun
Structural failure of general cargo vessel Swanland resulting in it sinking with loss of 6 lives
Investigation of Swanland’s structural failure and foundering in the Irish Sea, with six crew lost. It examines concentrated limestone loading, wave-induced stresses, probable corrosion-related weakening and survey and maintenance shortcomings. Wreck surveys and structural modelling inform the analysis, alongside practical assessment of immersion-suit dexterity, lifejacket compatibility and abandonment arrangements.
- 2013May
Flooding and sinking of potter Purbeck Isle with loss of 3 lives
Investigation into the loss of the commercial whelk potter Purbeck Isle and her three crew. Rapid flooding following hull-fastening failure was considered the most likely sinking mechanism. The report examines deteriorated hull condition, loading, bilge pumping, failed liferaft deployment, absent automatic distress signalling and shortcomings in inspection arrangements.
- 2013May
Grounding of feeder container vessel Coastal Isle
Investigation of Coastal Isle’s grounding at Bute during passage from Belfast to Greenock. The report examines an unattended bridge, unused watch alarms, fraudulent competency certification, delayed notification of shore authorities and disabled voyage recording. Recommendations address recorder functionality and certification, preservation of accident data and verification of seafarers’ qualifications.
- 201315 Feb
Lower Marine Riser Package (LMRP) Connector Failure
This alert describes multiple incidents involving loss of integrity in LMRP H-4 connector bolts. It outlines BSEE directions to affected operators to suspend operations pending bolt replacement or recertification, with independent certification requirements. It also reports at least one similar failure outside the US Gulf of Mexico.
- 201329 Jan
Safety Alert 303 - Lower Marine Riser Package (LMRP) Connector Failure
BSEE reports synthetic-base mud discharge following an LMRP H-4 connector integrity failure and additional connector bolt failures. Preliminary evidence identified hydrogen-embrittlement-related stress corrosion cracking as a contributor, with improper electroplating treatment a possible cause. The alert calls for affected-bolt identification, independent certification and vendor quality-assurance reviews, including heat-treatment compliance.
- 2013
Offshore installation moorings
This information sheet explains offshore mooring requirements for permanently moored installations and mobile units. It addresses design standards, weather robustness, thruster assistance, inspection criteria, tension and position monitoring, line-break response and failure reporting. Location-specific analyses and anchor verification are discussed alongside safety-case duties and verification arrangements.
- 2012May
Grounding of container vessel Karin Schepers
Investigation of Karin Schepers’ grounding near Pendeen examines the master falling asleep, fatigue, probable alcohol contribution, absent lookout and unused bridge watch alarm. It analyses refloating decisions, coastguard intervention powers, emergency checklists and safety-management audits. Recovered voyage data recorder information supplied the accident’s complete record; the vessel refloated without damage.
- 2012Apr
A guide to the Pipelines Safety Regulations 1996
Explains the Pipelines Safety Regulations 1996 across pipeline design, construction, operation, maintenance and decommissioning. Addresses operating limits, pressure testing, containment integrity and emergency shut-down valves, alongside additional duties for major accident hazard pipelines, including prevention documentation, notifications, safety management and emergency planning.
- 2012Apr
Asbestos - The survey guide
Guidance for dutyholders and surveyors on planning and conducting asbestos surveys, distinguishing management surveys from intrusive refurbishment and demolition surveys. Covers competence, representative bulk sampling, protective measures, material assessment and reporting. Explains how findings support current asbestos registers, risk assessments and management plans, with practical recognition guidance and survey quality assurance.
- 201130 Dec
Offshore OHS legislative framework information paper
This information paper explains Australia’s performance-based offshore OHS regime, distinguishing operators’ duties from the regulator’s assurance role. It describes safety-case acceptance, sampled inspections of safety-management implementation, and investigation criteria and enforcement outcomes, with responsibility for safe operation remaining with the facility operator.
- 2011Oct
Collision between 2 rigid inflatable boats carrying a number of children resulting in 3 people injured
Investigates a collision between two yacht-club rigid inflatable boats carrying children across Cardiff Bay’s freshwater lake at night. Three students were injured. The report examines unlit operation at about 20 knots, driver qualifications, passenger seating and capacity, missing risk assessments, safety equipment, medical contingencies and oversight of club and harbour safety arrangements.
- 2011Oct
Planning to do business in the UK offshore oil and gas industry?
Guidance for companies entering the UK offshore oil and gas industry explains goal-setting health and safety law, duty-holder responsibilities and HSE oversight. It outlines safety-case acceptance, independent verification, offshore regulations, contractor and employee duties, incident reporting, and the division of responsibilities for environmental, marine and aviation regulation.
- 2010Jul
Collision between offshore circuit racing powerboats Sleepwalker and Harwich 2011 with loss of 1 life
MAIB examines a fatal collision between Sleepwalker and Harwich 2011 during powerboat racing in Dover harbour. Video analysis and specialist racing advice supported the investigation. The report discusses hooking, course design, conflicting rules, risk assessment, racer competence, helmet limitations and safety-management oversight, while recognising the effective on-water emergency response.
- 2010Apr
Girting and capsize of tug Ijsselstroom
Investigation of Ijsselstroom’s girting, capsize and sinking at Peterhead during stern towing while moving astern. It examines hydrodynamic and static stability, absent bridle protection, towing-winch release arrangements and wheelhouse ergonomics. Findings and recommendations address skipper training, operational briefings, risk assessment and port oversight; fatigue was not considered contributory.
- 2010Mar
A guide to the Offshore Installations (Safety Case) Regulations 2005
Explains the 2005 offshore safety-case regulations, including duty-holder responsibilities, submission, acceptance and continuing review. Covers major-accident risk evaluation, contractor management, independent verification of safety-critical elements, well-operation notifications and dismantling revisions. Distinguishes notifications from accepted safety cases and explains that acceptance does not guarantee installation safety.
- 2009Sep
A guide to the well aspects of the Offshore Installations and Wells (Design and Construction etc) Regulations 1996. Guidance on Regulations
Explains the well provisions of DCR 1996, covering life-cycle integrity, subsurface assessment, material suitability, well-control equipment and examination schemes. It addresses operator responsibilities, reporting and competence, including suspension and abandonment, and clarifies interfaces with offshore safety cases and installation verification across offshore and land-based operations.
- 2009Jul
Key Programme 3 - Asset Integrity
HSE reviews UK offshore oil and gas industry progress following KP3, combining sample inspections, industry assessments, hydrocarbon-release analysis and a workforce survey. It examines safety-critical maintenance, verification, leadership and workforce involvement. Remedial improvements are reported, alongside continuing concerns about fabric condition, assurance, significant releases and safety-case consultation.
- 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.
- 2009Jun
DOE Human Performance Improvement Handbook, Volume 2
This handbook presents illustrative human-performance practices for individuals, teams and managers. It covers task preparation, self-checking, procedure use, communication, verification and handover, alongside organisational assessment, incident investigation and learning. Management tools address latent weaknesses, reporting culture and performance indicators. The practices are not requirements and do not guarantee error-free work.
- 2008Sep
Girting and capsize of tug Flying Phantom while towing bulk carrier Red Jasmine with 1 person injured and loss of 3 lives
Investigation of Flying Phantom’s fatal girting and capsize while assisting Red Jasmine on the River Clyde in thick fog. It examines delayed towing-winch emergency release, reduced stability with an open watertight door, blind-pilotage arrangements and deficient port risk management. Recommendations address restricted-visibility towage limits, training and independent safety-management assurance.