Control
Energy and Process Isolation
Separation from hazardous energy or process sources.
Newest 100 Documents
All 397 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.
- 202612 Aug
Improper Use of Hand Tools and Unplanned Deviations from Job Tasks Results in Injuries
Two construction workers sustained facial lacerations during bolt removal: one from an ejected pneumatic rivet-buster piston during troubleshooting, the other from reciprocating-saw kickback after changing tools and removing a face shield. The alert recommends considering pneumatic isolation, manufacturer instructions, job safety analysis updates and stopping work when tasks or protective equipment require reassessment.
- 202610 Aug
United States Steel Corporation Clairton Plant Coke Oven Explosion
Investigates the fatal Clairton coke works explosion during high-pressure water washing of a cast-iron isolation valve. Overpressurisation caused valve failure and a coke oven gas release. The report examines maintenance procedures, hazard assessment, occupied-building siting and process safety governance, supported by valve examination and causal analysis.
- 2026Mar
Decontaminate Before Opening! — Process Safety Beacon, March 2026
A contractor suffered acid burns when residual hydrogen fluoride escaped during flange maintenance after incomplete piping decontamination. The bulletin examines missing drawings, vacuum and nitrogen purging, and reduced protective clothing. It stresses field verification of isolations, clearing trapped material and retaining full protection until piping is proven free of hazards.
- 202613 Feb
BSEE: Miscommunication and trapped pressure causes injury during valve maintenance
An offshore valve-maintenance incident injured a worker when trapped gas pressure ejected a bonnet flange. This flash summarises BSEE findings on incomplete authorisation, inadequate isolation verification, miscommunication, unsafe scaffold use and omitted retaining nuts. Recommendations emphasise confirming zero stored energy, reviewing task assessments, following manufacturer instructions and considering two-person working.
- 2026Jan
Decommissioning
A regulatory checklist for temporary and permanent well abandonment under Subpart Q. Questions cover prior approval, isolation of open-hole zones and perforated intervals, cement plugging, conditional pressure testing, plug integrity, residual fluid density and wellhead removal. It also checks installation of two independent wellbore barriers, including a mechanical barrier.
- 20253 Dec
BSEE Safety Alert - 509 - Miscommunication and Trapped Pressure Causes Injury
An offshore contractor was injured when trapped gas pressure ejected a bonnet flange during control-valve maintenance. The alert identifies unverified isolation, missing authorisation, miscommunication, unsafe scaffold use and omitted retaining nuts. Recommendations address zero-energy verification, collaborative job safety analysis, operational support, fall protection and adherence to manufacturer procedures.
- 20257 Nov
ATSB: Undocumented modification contributed to steam burns
An oil tanker maintenance team suffered burns when hot condensate escaped during steam valve bonnet removal. The ATSB found insufficient cooling time and an undocumented drain-line modification that likely weakened isolation. The flash highlights formal management of change, recording and assessing changes, adequate cooling and visual confirmation of isolation.
- 2025Nov
PPE only works when you wear it correctly! — Process Safety Beacon, November 2025
This Beacon examines a California refinery release during pressure-gauge replacement, where ineffective isolation and absent respiratory protection increased harm from hydrogen sulphide exposure. It explains limitations of personal protective equipment and stresses task-specific procedural requirements, correct use, pre-use inspection and regular checks of condition and respirator cartridge expiry.
- 20252 Oct
Worker suffered eye injuries in electric arc incident
A vessel electro-technical officer suffered light eye burns from an electrical arc while disconnecting a shore power cable that appeared still energised. Initial findings identified inadequate vessel–quayside communication and documentation. The flash emphasises voltage testing, isolation, improved communication, risk assessments and toolbox talks.
- 202530 Sep
BSEE Safety Alert 506 - Arc Flash Incident Highlights Critical Need for Voltage Verification During Offshore Electrical Maintenance
An offshore platform cable installation resulted in an arc flash and a minor thermal burn when an electrician used non-insulated pliers inside an energised motor control centre. The alert identifies deficient task analysis and communication, recommending de-energised working where feasible, insulated tools, arc-rated protection, coordinated cable movements and competency assurance.
- 2025Aug
Excavators : Use of safety control lever or isolation devices
This safety notice addresses unintended excavator movement and correct use of safety control levers or isolation devices. It describes a fatal crushing during lifting after inadvertent joystick contact caused slewing, and sets out expectations for isolation, monitoring, safe-approach communication, risk assessment and operator and slinger competence.
- 2025Aug
Thermal Expansion runs hot and cold! — Process Safety Beacon, August 2025
This bulletin explains how heating trapped liquids and freezing accumulated water can rupture process pipework. Two chemical-processing incidents illustrate releases, fires and injuries involving a burst strainer and cracked propane piping. It highlights pressure relief, established isolation and depressurisation procedures, accommodation of thermal movement and temperature-dependent freezeproofing.
- 202531 Jul
Near miss: High voltage arc inside tether termination manifold
A dislodged HPU conductor caused arcing inside an ROV tether termination manifold. Subsequent checks identified reduced insulation resistance and gas, whose origin was unconfirmed without testing. The flash examines unapproved termination lugs and records re-termination, system testing and recommendations to assess crimping tools and review procedures and gas-venting precautions.
- 20253 Jul
High potential incident: Worker injured when opening a flanged assembly
A worker dismantling emergency shutdown valves on deck sustained a forehead wound when trapped line pressure expelled a gasket. The flash identifies missing pressure checks and monitoring after isolation, alongside water ingress during subsea diving work. Actions included supervised pre-start checks, pressure-checking and venting hold points, and closer line monitoring.
- 202518 Jun
Lock out/Tag out and unauthorised electrical connections/disconnections
This flash describes missing electrical and mechanical lockouts identified during a vessel engine-room audit, alongside unauthorised electrical disconnections and bypasses. It emphasises suitable lockout devices, documented approval of temporary modifications, restoration checks and clear handovers. Possible links to dynamic positioning trials are presented as assumptions rather than established causes.
- 202529 Apr
Detergent chemical burn
An electrician and trainee suffered slight chemical burns from leaked detergent during dishwasher repairs aboard a vessel. Electrical isolation was addressed, but corrosive detergent hazards and labelling were overlooked. The flash highlights secondary hazards, stakeholder involvement, clear hazard identification and appropriate PPE for unidentified liquids.
- 20256 Feb
Saturation diver exposed to chemicals from pipeline
A saturation diver suffered chemical burns after exposure to chemically treated seawater while disconnecting a pigging/flushing hose during decommissioning. The flash identifies uncertainty over flushing and absent engineered barriers. Lessons address understanding pipeline contents, hazard analysis, amended procedures, valve isolation and securing, and reducing exposure through local valves.
- 202523 Jan
Accident to chief engineer on board motor yacht Baton Rouge with loss of 1 life
Investigation of a chief engineer’s fatal electrocution during ventilation damper actuator replacement aboard Baton Rouge in Antigua. It examines work on a live circuit, unused permit arrangements, heat, inadequate monitoring and rescue planning, and conflicting enclosed-space definitions. Management revised its procedures; the report makes no recommendations.
- 202412 Nov
Diver exposed to unplanned release of production gas
A saturation diver removing a blind stab from a subsea skid was pushed backwards by released production gas but remained unharmed. The flash identifies unverified isolation, deviation from procedures, inadequate review of task risks and unused ROV tooling. It highlights change management, procedural hold points and reinforcement of stop-work authority.
- 2024Oct
Some short-cuts may cut lives short — Process Safety Beacon, October 2024
This bulletin examines procedural shortcuts through a fatal polyethylene reactor incident in Pasadena, Texas. It describes inadequate isolation, unenforced permits and cross-connected valve air hoses. Guidance stresses operational discipline, functioning safeguards and authorised assessment of changes, warning against treating temporary safeguard bypasses as routine practice.
- 202414 Aug
MSF: Serious hand injury – high pressure air
During a vessel fire drill, a crewmember assisting with breathing apparatus suffered a finger injury from high-pressure air released through a cylinder valve’s pilot vent hole. Surgical treatment was required. The flash relays MSF recommendations on connection tightening, leak checks, breathing checks and low-pressure alarm testing.
- 202416 Jul
Electric shock after water ingress to switch
A vessel visitor received an electric shock from a steering-room switch left live and unprotected after maintenance. Water entered during engine-room washing following major repairs. The flash highlights completing maintenance before reinstatement, isolating and protecting electrical connections during cleaning, and recording regular competent inspection and testing.
- 202416 Apr
BSEE Safety Alert - De-pressurizing Piping to Remove Hydrate Results in an Injury
An offshore platform operator suffered bruising and swelling when a ball valve assembly separated during depressurisation of gas lift piping containing a possible hydrate. Approximately 900 psi remained trapped behind the valve. The alert discusses inadequate isolation, missing task hazard analysis, and measures operators should consider for hydrate prevention and safe pressure bleeding.
- 202416 Apr
Improperly Depressurizing Piping to Remove a Hydrate Causes Injury
An offshore platform operator suffered bruising and swelling when a valve assembly detached during depressurisation of gas lift piping containing a possible hydrate. Approximately 900 psi was trapped behind the valve. The alert recommends considering energy isolation, balanced bleeding, task hazard analysis, management of change and gas dehydration.
- 202427 Mar
Loss of heading control on an FPU during diving operations
A floating production unit lost heading control during diving operations when a steering pump failed to start automatically during greasing. Only one thruster was available. Divers were recovered safely. The flash examines maintenance coordination, work permits, risk assessment and communication, and calls for changes to the company SIMOPS matrix.
- 20249 Jan
Chain hoist paid out unsupervised near running main engine
An unattended electric chain hoist aboard a vessel paid out onto a running main engine near the generator drive shaft. A defective pendant button issued a continuous payout command. The flash examines operator assumptions, unsecured stowage and the unused emergency stop, and recommends checks, isolation review and maintenance review.
- 202321 Dec
KMCO LLC Fatal Fire and Explosion
Investigation of the fatal isobutylene explosion and fire at KMCO’s Crosby facility. Metallurgical testing established pressure-driven brittle fracture of a cast-iron y-strainer. The report examines thermal-expansion hazards, manual versus remote isolation, emergency-response roles and alarm use, identifying weaknesses in hazard evaluation and response that contributed to the incident and its severity.
- 202318 Dec
Failure of personal isolation procedures: Crane became damaged when it was used inappropriately
A crane aboard a vessel in dry dock was damaged when crew attempted to operate it during hydraulic repairs. Personal isolation had been used across several days by multiple people and removed for testing. The flash highlights inadequate risk assessment, the missing permit to work and restrictions on personal isolation.
- 20237 Dec
Accidental discharge of condensed aerosol fire-extinguishing system on beam trawler Resurgam with loss of 1 life
Investigation of a fatal accidental aerosol fire-extinguishing system discharge during installation aboard Resurgam in Newlyn harbour. It examines electrical commissioning, generator placement, toxic combustion products and impaired escape. Laboratory trials inform analysis of inhalation hazards, while findings address installer competence, regulatory approval, contractor coordination and rescue arrangements.
- 202327 Nov
Failure of proportional valve in saturation chamber control
A proportional valve feedback fault interrupted saturation diving, without injury or equipment damage. Automatic safeguards isolated the line and transferred control to a manual valve. Unauthorised dismantling obscured the origin of potentiometer damage; debris was also found. Lessons address manufacturer-led maintenance, critical spares, training and testing before diving resumes.
- 202317 Aug
Engine room fire on LPG carrier Moritz Schulte with loss of 1 life
Investigation of a fatal engine-room fire aboard Moritz Schulte in Antwerp. Pressurised marine gas oil escaped during inadequately isolated fuel-filter cleaning and ignited on an adjacent engine’s hot exhaust. The report examines maintenance arrangements, competence assurance, escape equipment and rescue coordination, including thermal imaging. No recommendations were made following actions already taken.
- 202315 Aug
Unplanned rotation of drilling machinery
A subsea drill unexpectedly rotated during planned maintenance on a vessel’s deck, breaking retention fastenings without injuring anyone. The flash identifies an unreconciled switch position, inadequate handover and excessive reliance on administrative controls. Subsequent actions included an isolation interlock, revised switching-off procedures and improved team communication and compliance monitoring.
- 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.
- 202329 Jun
Watson Grinding Fatal Explosion and Fire
Investigation of the Houston propylene explosion that killed two employees and a nearby resident. It examines a degraded, poorly crimped hose, inconsistent supply isolation and non-functional automated safeguards. Findings address process safety management, change assessment, emergency preparedness and regulatory exclusions; lighting activation is identified as the likely ignition event.
- 202315 Jun
Wacker Polysilicon Chemical Release
This investigation examines a hydrogen chloride release during heat-exchanger maintenance at Wacker Polysilicon. Excessive bolt torque fractured a graphite nozzle; three workers fell while escaping, with one fatality. The report analyses maintenance instructions, hazardous-energy control, simultaneous insulation work and restricted egress, recommending clearer procedures, coordinated operations and additional escape routes.
- 202325 May
LyondellBasell La Porte Fatal Chemical Release
This investigation examines the fatal chemical release during plug-valve actuator removal at LyondellBasell’s La Porte complex. Two workers died following exposure to acetic acid and methyl iodide. It compares similar incidents and examines valve design, pressure-retaining components, work procedures, training, isolation and pre-authorisation risk assessment.
- 202316 May
Differential pressure: Dummy choke ejected close to divers
A dummy choke insert was expelled by differential pressure during replacement work near two divers, who remained unharmed. The flash examines absent local venting, misunderstood pressure readings and unclear release expectations. It recommends explicit procedures and risk assessments, isolation training, confirmation of an open local vent and clarification of questionable instructions.
- 20233 May
Equipment starts unexpectedly
Three mechanics were maintaining a high-voltage AC unit under lockout/tagout when it restarted unexpectedly. A broken circuit-breaker handle linkage had prevented shutdown. Nobody was injured. The flash highlights verification of de-energisation and correct energy-source isolation, including when equipment is upgraded or modified.
- 20233 May
Near miss: Steam and water released from filter
A mechanic cleaning boiler circulation pump strainers encountered an unexpected steam and water release. The isolation valve had not fully closed; a supervisor subsequently closed it further. Revised procedures specified opening the filter bypass before inlet and outlet isolation, followed by upstream and downstream draining and purging to ensure zero energy.
- 2023May
LPG forklift truck fire risk
This safety alert addresses fires during starting of LPG-powered forklift trucks and similar vehicles. Fuel-system deposits can cause valves to stick, while repeated starting attempts can release unburned gas. It specifies operator precautions and maintenance actions, including stopping further starting attempts, isolating the gas supply and ensuring ventilation.
- 202320 Apr
BSEE: Person injured when safety mechanisms failed
An offshore sandblasting worker sustained head and shoulder injuries when a T-connection detached and a whip check failed. The flash discusses improper cable crimping, slightly corroded baling wire and stresses from horizontal hose positioning. Recommendations address additional securing, fitting orientation, pre-job inspection and depressurisation before valve adjustment where practical.
- 202323 Mar
Safety warning issued about the hazards of flexible hose installations
MAIB examines a Finnmaster engine-room fire caused by a flexible fuel hose overheating after an exhaust leak, releasing marine gas oil onto a hot surface. The bulletin discusses hose length, routing, inspection difficulties and unapproved alarm-system modifications, highlighting modification risk assessment, classification requirements and isolation valves.
- 202327 Feb
Battery explosion during routine maintenance
A harbour tug’s Chief Engineer sustained minor injuries when a spanner inadvertently short-circuited a battery during preparations to replace a failed disconnect switch. The flash discusses electrical isolation, terminal protection, suitable tools and protective equipment, alongside increased maintenance inspection and consideration of chargers with temperature sensors.
- 202317 Feb
Person Injured when Safety Mechanisms Failed
A sandblasting worker on a Gulf of Mexico offshore facility suffered head and shoulder injuries when a T-connection released and a whip check broke. The alert discusses improper crimping, potentially weakened baling wire and hose orientation, recommending improved securing, pre-job assessment, equipment checks and depressurisation when practical.
- 202316 Feb
LTI: Person crushed in watertight door
An electrician suffered severe crushing injuries when a vessel’s watertight door opened during proximity-sensor adjustment. A damaged selector switch enabled the opening command, while a leaking ball valve failed to isolate the hydraulics. The flash highlights absent work authorisation, lockout and task analysis, and recommends adequate replacement spares.
- 2023
CHIRP Fisher Feedback Autumn 2023
CHIRP’s first commercial fishing newsletter examines pot-line propeller fouling, a conveyor fingertip injury, a lone fisher falling overboard, failed trawl hoisting, a ferry collision and recovered unexploded ordnance. Case commentary discusses maintenance isolation, work communication, wire-rope inspection, harbour navigation and personal emergency signalling and self-rescue arrangements.
- 202229 Dec
Husky Energy Superior Refinery Explosion and Fire
Investigation of the Superior refinery explosion during fluid catalytic cracking shutdown. It examines air entering hydrocarbon equipment, missing steam-barrier and purge safeguards, eroded slide valves, procedural and training deficiencies, and brittle vessel fragmentation. Debris punctured an asphalt tank, escalating the event into fire; recommendations address transient-operation safeguards and emergency preparedness.
- 202221 Dec
Dummy hot stab ejected during leak investigation
A pressure-test near miss involved an incompatible dummy hot stab ejecting from its receptacle while personnel stood nearby but outside the direct line of fire. The flash identifies missing retention, undocumented work controls and inadequate barriers, and recommends secure compatible fittings, safe-distance exclusion zones and depressurisation before investigating leaks.
- 202219 Dec
TPC Port Neches Explosions and Fire
An investigation using AcciMap examines dead-leg management in high-purity butadiene service. Its causal analysis identifies an unimplemented process hazard analysis recommendation and a flushing procedure that was not carried out. It also records gaps in requirements for remotely operated emergency block valves on existing equipment.
- 202213 Dec
Oil tank sight glass push buttons wired open
An engine-room visit identified oil-tank sight-glass push buttons deliberately held open with wire, defeating the gauge’s closing feature. The flash explains that accidental damage to the glass tube could allow tank contents to spill, creating slip and fire hazards and depriving equipment of its intended oil supply.
- 202230 Nov
MAIB: A scalding injury
An engineer aboard a cruise ship suffered severe facial scalding after opening an isolated economiser’s drain valve before cooling was complete. Hot water and steam discharged and deflected upwards from a tundish. The flash highlights discharge-path exposure, caution when opening pressurised drain lines, and controlled valve operation using a correctly sized wheel key.
- 20221 Nov
Failure to plan properly: electrician sustains serious burns (UK HSE)
An electrician suffered serious burns at a supermarket warehouse when his metal spanner contacted a live busbar, causing an electrical explosion. Generator connection work alongside high-voltage maintenance lacked adequate planning and contractor coordination. The flash highlights failures to stop the circuit supply and appoint a competent person to organise the work.
- 20221 Nov
Live sub-surface power cable inadvertently cut
An excavator cut an energised buried power cable during onshore pipeline trenching, without injuries or equipment damage. Incomplete as-built information and misleading drawings left the cable hazard unidentified in risk assessment. The flash highlights isolation, cable tracking during excavation planning and clear communication of stop-work authority.
- 202211 Oct
Philadelphia Energy Solutions (PES) Refinery Fire and Explosions
Investigates the PES refinery fire and explosions following corrosion-induced rupture of an elbow in its hydrofluoric acid alkylation unit. Examines material composition, inspection coverage, vessel failure, unavailable remote isolation and impaired water-spray mitigation. Contrasts successful rapid acid deinventory with failed safeguards and assesses alternative alkylation technologies and regulatory recommendations.
- 202228 Sep
Sunoco Logistics Partners Flash Fire
Investigation of a flash fire and explosion during flange welding at Sunoco’s Nederland terminal, injuring seven contractors. The report examines residual crude oil, pipe isolation tools, atmospheric testing, permits and procedure implementation. It discusses similar incidents and stresses ensuring a non-flammable internal atmosphere before hot work; the specific causal scenario remains unresolved.
- 20225 Sep
Personal injury – burns from hot engine oil to body and face
An engineer suffered burns when hot fuel sprayed onto his body and face while opening a main-engine fuel oil filter aboard a vessel alongside. The flash identifies inadequate risk assessment, improper compressed-air isolation, omitted pressure checks and draining, and failures to follow procedures. Lessons emphasise thorough assessment, supervision and adherence to instructions.
- 202226 Jul
MSF: CO2 system left non-operational after servicing
A vessel’s fixed CO2 firefighting system remained inoperable because survey safety pins were not removed, discovered almost four weeks later. The flash reinforces owner-specific lessons on isolation records, considering permits to work, inspecting contractor reinstatement and circulating safety learning, while noting that incident-specific causes and corrective actions were not supplied.
- 202214 Jul
Don’t ASSUME – verify and check
This safety flash examines three incidents involving an unverified slip-ring isolation, a scaffold plank falling when a roller box opened, and workers exposed to moving machinery. It identifies assumptions and incomplete work-control documentation, emphasising completion of authorisation processes, verification of safeguards and speaking up to stop unsafe work.
- 202220 Jun
High potential: electric shock near miss
An engineer received a minor shock while troubleshooting a faulty 690V motor using a multimeter. The junction-box cover touched one phase during replacement; no injury was confirmed. The flash examines an unassessed change to live electrical work, missing isolation and authorisation, inadequate gloves, and subsequent requirements for crew discussion before work.
- 2022Jun
CHIRP Maritime FEEDBACK 67
Maritime incident reports examine risk acceptance through undocking damage, unsafe access over timber cargo, power and detection failures, collisions, cargo-control distraction, grounding, sinking and boiler repair. Commentary addresses testing, isolation, familiarisation and challenge culture. Additional material describes tug-use training and a pilot-boarding safety checklist.
- 202231 May
MSF: Corrosion in fire-fighting equipment
A vessel’s monthly inspection identified significant corrosion in its fixed CO2 firefighting system, preventing insertion of the cylinder isolation safety pin for maintenance. Corrective repair restored alignment. The flash stresses regular care and checks in accordance with manufacturers’ recommendations to keep critical firefighting systems ready for activation or isolation.
- 202231 May
USCG: Exceeding electrical duty rating can lead to failure
A rescue-boat winch continued hoisting after its motor contactor fused because its duty rating was exceeded. Crew isolated power before the boat contacted the davit. The flash relays USCG recommendations to check contactor condition, compare duty ratings with recovery practices, verify safety-device design and train operators in power isolation.
- 202212 May
Process Safety Fundamentals – IOGP / Step Change
This safety flash summarises IOGP’s Process Safety Fundamentals through a Step Change in Safety learning pack suitable for safety meetings and toolbox talks. It highlights recognising change, stopping when work departs from expectations and investigating weak signals, alongside procedures, barriers, operating limits, isolation and ignition control.
- 20228 Apr
USB power bank (Lithium battery) fire
A lithium-polymer USB power bank caught fire while charging in a vessel cabin. The crew member smothered the flames, disconnected mains power and used water for cooling; no injuries occurred. Findings suggested failure within the power bank. Recommendations address supervised charging and unplugging fully charged units.
- 20221 Mar
Galley and Living Quarter Fires
BSEE summarises reported galley and living-quarter fires and electrical faults involving cooking appliances, dryers and a stateroom receptacle. Cases include damaged ignitor wiring, dryer overheating and liquid-induced short circuits. Operators are encouraged to consider equipment servicing, electrical inspections, unplugging during specified tasks and regular fire-extinguisher inspection and servicing.
- 202228 Feb
Permit to Work and Isolation procedure not followed
An electrician replacing fuses in a live 930V DC vessel drive cabinet experienced an arc flash without injury. The flash examines absent work permits, unsecured and untagged isolation, inadequate procedures and failure to check isolation before work. Actions focus on reviewing work controls and following workplace instructions.
- 202228 Feb
UK HSE: Poor control of work – worker suffered serious injuries
This safety flash describes serious hand and arm injuries during conveyor repair when the line restarted. The supervisor became distracted before completing the permit to work and isolation. It reports the supervisor’s sentencing for safety breaches and highlights failure to implement company procedures for these controls.
- 202210 Feb
NTSB: Engine Failure leads to fire aboard offshore supply vessel
This safety flash summarises an NTSB finding on a generator engine failure aboard an anchored offshore supply vessel. Bearing seizure was identified as the probable cause of rod ejection, oil release and an engine-room fire. Crew removed fuel and oxygen sources, containing the fire without injuries or pollution.
- 202228 Jan
Incorrect as-built drawing configuration
Divers investigating leaks at a subsea manifold followed approved procedures based on incorrect client information. Fault-finding revealed a different jumper configuration, leaving only one unproven barrier during intervention. Work stopped pending confirmation of safety; the client investigated without identifying how the error arose, and amended drawings were formally approved.
- 202116 Nov
Electric Arc Flash Management
This bulletin examines arc flash hazards and their management on offshore petroleum facilities, drawing on incident notifications and inspection findings. It explains risks during isolation and proving equipment dead, including low-voltage hazards, and discusses engineering measures, procedural controls, training and arc-rated protective equipment alongside operators’ statutory duties.
- 202131 Aug
UK HSE: Poorly maintained electrical installation caused fatality
An IMCA safety flash describes a fatal electrocution during planned air-compressor maintenance and the subsequent HSE prosecution. Findings included inadequate electrical-contact controls, absent testing and visual inspection since installation, and an unidentified incorrect isolating switch. The account highlights correct isolation points, training, supervision and safe systems of work.
- 202130 Jul
Fault in high voltage equipment
A vessel’s portable seismic sparker produced sparks at its -5600V terminals during initial testing. Investigation identified incorrect washers and bolt threading that could prevent full tightening. Training time was reduced and reporting delayed four weeks. Recommendations address competence, risk assessments, stopping work, power isolation and prompt investigation.
- 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.
- 20218 Apr
Shipyard worker receives electrical shock
A welder aboard a dry-docked vessel received an electric shock while routing a damaged 380V extension cable through pooled water. The flash identifies exposed cores, absent pre-use inspection, missing residual current protection and wet gloves. Actions address equipment checks, quarantine of defects, circuit protection, emergency isolation and weather-sensitive risk assessment.
- 202117 Mar
Electric shock due to water in electrical equipment
During freshwater supply to a vessel, water escaped from a galley sounding pipe and wetted cooking equipment. A steward received a mains electric shock but was unharmed. The flash identifies unassessed spill risks and delayed drainage, and recommends open drainage, revised risk assessments and communication of equipment maintenance requirements.
- 202117 Mar
Offshore Pipeline Integrity Management (Issue 2)
Inspection guidance for assessing offshore hydrocarbon pipeline integrity management, compliance and performance. It addresses ageing and life extension, corrosion monitoring, pipeline and riser inspection, shutdown valve testing, pigging safeguards and emergency preparedness. Success criteria, sample inspection agendas and enforcement assessment guidance support examination of operators’ arrangements.
- 202111 Feb
Failure of remote control/emergency stop on rescue boat winch
During rescue-boat recovery, remote control and emergency-stop functions failed, and the limit switch did not stop retrieval. Inspection found a contactor stuck closed; frequent short switching intervals were considered the most probable cause. The flash emphasises correct retrieval procedures, component inspection and replacement, and regular emergency-stop function testing within planned maintenance.
- 20212 Feb
Hand injury when caught in machinery
A crew member suffered hand and arm fractures during humidifier maintenance when airflow drove an electrically isolated fan and belt. His glove became entangled, drawing his hand and forearm into the machinery. Re-enactment identified an open ventilation outlet condition; the flash calls for procedures to address the previously unrecognised hazard.
- 202026 Nov
Cabin fire caused by light fitting overheating
A minor fire in an unoccupied vessel cabin bathroom followed an internal short or failure in a ceiling light fitting. Its melted plastic cover ignited the toilet lid. The flash recommends cabin and light-fitting inspections, conditional electrical isolation, ready firefighting equipment and safe alarm-raising and response.
- 2020Oct
Process Safety Fundamentals (IOGP Report 638)
Guidance introduces ten Process Safety Fundamentals for upstream operations, with downstream applicability also proposed. It addresses procedures, barriers, operating limits, isolation, ignition sources, change and unexpected conditions. Implementation guidance emphasises organisational engagement and coaching, supported by analysis of fatal and non-fatal process safety events and discussion of performance indicators.
- 202015 Sep
UK HSE: Two workers suffer multiple burn injuries
Two workers, including an apprentice, suffered life-changing burns during reassembly of high-pressure steam pipework following maintenance of a steam turbine driven pump. Steam was released uncontrollably at around 250°C. The investigation identified safe-system-of-work failures, including incomplete checks and verifications required by the steam isolation procedure.
- 20204 Sep
High potential DROPS near miss: Failed crane component
A crane’s man-riding brake casing failed during preparation, dropping components to the deck without injury. Investigation identified hydraulic overpressure and incorrectly set relief valves, with commissioning changes insufficiently evaluated. The flash describes isolation by blanking and recommends valve adjustment checks and reviews of change management, commissioning, competence and maintenance procedures.
- 202025 Aug
Electrical shock from containerised portable office
An employee received a mild electric shock while tidying a containerised office, touching live wiring hidden beneath a desk. The cable remained after equipment removal during storage. The flash identifies missed checks and absent electrical verification, and describes isolation, inspection and formal instructions for container fit-out and modification.
- 202028 Jul
Sudden Uncontrolled Pressure Release
Hazard alert addressing sudden pressure releases during commissioning, decommissioning, maintenance and repair in the oil and gas industry. It identifies equipment integrity problems, changing conditions and unsafe work practices, and outlines employer and worker responsibilities for assessments, isolation, controlled depressurisation, safe procedures and avoiding released-energy paths.
- 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.
- 20201 Jun
UK HSE: Workers injured by unplanned release of mud slurry
Three contractors suffered multiple fractures when approximately 39 cubic metres of diluted slurry escaped during recirculation pump removal for maintenance. A blocked drain had prevented discharge of pressurised contents before work began. The flash reports inadequate risk assessment and failure to implement a safe system of work.
- 202012 May
Air suspension systems on vehicles
HSE alert addresses vehicle air suspension incidents involving collapse, unexpected movement and pressurised component ejection. It recommends minimal roadside repairs, suitable chassis support or full deflation, exhausting stored air and physical air-supply disconnection. Task planning and a staged leak-checking method are described, with warnings against pipework clamping for isolation.
- 202031 Mar
Agitator started moving during mud tank cleaning – leading to injury
A contractor cleaning a vessel’s mud tank was struck by an unexpectedly starting agitator, suffering bruising and a broken rib. The flash examines omitted isolation, inadequate risk-assessment review and unclear departmental and contractor responsibilities. Actions address physical verification, lockout and tagging, isolation certification and improved communication.
- 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.
- 2020
The safe approach, set-up and departure of jack-up rigs to fixed installations (REV 1)
Guidance for duty holders managing jack-up approach, positioning and departure beside fixed offshore installations. It examines collision and hydrocarbon-release risks, pipeline protection, human factors and personnel limits. Site-specific ALARP demonstrations underpin decisions on production shutdown, depressurisation and venting, with live approaches requiring justification of changed circumstances.
- 201912 Nov
Use of surge protected devices on-board vessels
A vessel’s surge-protected extension lead overheated and burned after its varistors heated and the breaker tripped. The flash explains the fixed-earth surge protection design and interaction with shipboard residual current devices. Actions included isolating and removing the lead, examining extension leads for electrical compatibility and removing unsafe items.
- 201930 Sep
Near miss – Diving operations while alongside
A main engine started while a diver cleared bow-thruster debris in a dockyard; the bridge immediately shut it down and the diver escaped unhurt. The flash identifies failures in communication, permits, lockout/tagout and risk assessment, and recommends physical isolation and verified control-of-work arrangements before diving.
- 201923 Aug
Near miss: Diver’s umbilical trapped
During near-shore diving, an untended umbilical drifted against a seawater intake screen and became trapped when the automated bar started. Emergency stopping and manual reversal freed it; neither diver was injured. The flash identifies absent isolation and inadequate supervision, and records reviews of risk assessment, dive planning and permit requirements.
- 201912 Aug
Seawater entering cabin caused electrical fault
A passenger cabin porthole left slightly open during vessel operations admitted seawater into an electrical socket, causing a short circuit, burnt wiring and smoke. Responders isolated the supply. The flash highlights vessel induction, watertight integrity inspections when leaving port and a safety discussion involving passengers and crew.
- 20194 Jun
Don’t put your finger in the wrong place: Failure to isolate equipment causes serious finger injury
An ROV manipulator repair resulted in the loss of approximately 1 cm of a worker’s left index finger while checking clevis and hydraulic shaft alignment. The flash identifies live hydraulics, unconsulted manuals and inadequate task risk assessment, and recommends hydraulic isolation, lockout/tagout and adherence to technical instructions.
- 201913 May
Near miss: Fire of electrical distribution board during diving operations
A barge lost electrical power during air diving at 18 msw when breaker removal created a short circuit and bus-bar flash fire. The diver was recovered using backup power without injury. The flash identifies failures in isolation, lockout/tagout, work permitting and communication between simultaneous electrical and diving operations.
- 201925 Apr
Hot water fitting failure results in 3m loss of depth in diving bell
A diving bell lost pressure during pre-dive checks following a cracked hot-water fitting. Impact from a diver’s bailout bottle was believed to have caused the failure. The team isolated the leak. The flash highlights effective drills, uncertain fitting replacement history, inspection for impact damage and recording critical components in planned maintenance systems.