Control
Management of Change
Assessment and authorisation of safety-relevant changes.
Newest 100 Documents
All 342 in search- 202627 May
Givaudan Sense Colour Explosion
Investigation of a fatal reactor explosion during caramel colouring manufacture in Louisville. A vent valve failed closed, accelerating sugar decomposition; cooling and emergency pressure relief capacity were inadequate. Calorimetry and component testing inform findings on reactive hazards, process safety implementation, operating limits, occupied-building siting and regulatory coverage gaps.
- 202615 May
Safety Bulletin - Lifting Operations Dangerous Occurrences and Injuries
NOPSEMA reviews recurring failures identified in offshore lifting incident investigations over the preceding five years. The bulletin highlights change management, role-specific competence, manufacturer guidance, drop-zone boundaries and control-of-work interfaces. It calls for rigorous application of systems to routine and non-routine lifts and consideration of control effectiveness and assurance.
- 202614 May
High Potential Near Miss: Dropped object due to contact with crane sheave
A vessel crane near miss involved a DP beacon striking sheave protection bars, detaching with its holder and falling to the deck. Nobody was injured. The flash examines wire-mounted attachment, absent secondary retention, unconsidered management of change and inadequate access controls, highlighting crane limits and third-party equipment coordination.
- 202615 Apr
UK HSE: electrician seriously injured on onshore wind farm
An electrician sustained life-changing injuries during substation maintenance at an onshore wind farm. The investigation identified departure from a prepared switching programme and inadequate checking and change approval processes. The flash highlights safe work systems, management of change, coordination of parallel tasks, electrical-work review and supervision.
- 202631 Mar
Change to the titleholder with operational control of activities guidance note
Guidance for petroleum titleholders on maintaining regulatory compliance when operational control changes. It explains continuing obligations under well operations management plans and environment plans, revised submissions, coordination with NOPSEMA and NOPTA, information access and transitional arrangements. It recommends aligning acceptance of revised plans with the transfer of operational control.
- 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.
- 202631 Mar
Offshore Inspection Guide Electrical Power Systems
An inspection guide for assessing electrical power systems and duty holder compliance. It addresses generation, distribution, protection, portable equipment and safe electrical work, with condition-monitoring methods including partial-discharge analysis, thermography and insulating-oil assessment. Performance scoring supports regulatory intervention planning; ATEX equipment is excluded.
- 202631 Mar
Staged WOMP submission process
NOPSEMA describes its preferred phased submission of well operations management plans, separating lifecycle management processes from construction, production and abandonment detail. The paper explains concept-selection and detailed-design submissions, risk registers, barrier acceptance criteria, change management and regulatory inspections, while allowing titleholders to retain their existing submission structure.
- 202617 Mar
Failure of A-frame fold-down platform
A hinged A-frame platform failed during sheave-block load checks aboard a vessel alongside for mobilisation, leaving a crew member suspended in their harness with minor injuries. The flash identifies missing cotter pins, hinge design flaws and galvanic corrosion, alongside omitted change management, scheduled maintenance and platform inspections.
- 2026Feb
Inherently Safer Principles — Process Safety Beacon, February 2026
Explains inherently safer design through an alkylation reactor sampling case. Consistent quality-control results supported reducing routine sampling from twice daily to weekly, with additional samples under specified changes or upsets. Introduces minimisation, substitution, moderation and simplification, and calls for management-of-change review before implementing identified options.
- 202627 Jan
Human Factors information paper - Critical task analysis
This information paper explains how critical task analysis supports identification and assessment of human error risk in offshore petroleum operations. It describes hierarchical and tabular task analysis, data collection, goal decomposition and plans analysis, then outlines risk assessment and a staged organisational approach to introducing the methodology.
- 202622 Jan
Dropped GRP cover during subsea lifting
A GRP manifold cover detached during subsea relocation and dropped approximately 7 m, without injury or damage to the manifold or bottom structure. Findings identified excessive loading during a crane mode transition and erroneous lifting-rod calculations. Revised lift planning removed the mode switch and used deployment lifting points; keeping divers clear prevented potential serious injury.
- 202622 Jan
Preparing an environmental performance report
Guidance for titleholders preparing environmental performance reports under Australian offshore petroleum regulations. It explains submission intervals, supporting records and recommended reporting structure, including performance outcomes and standards, emissions and discharges, monitoring, incidents and changes to environment plans. Decommissioning reporting and example compliance tables are also covered.
- 202522 Dec
Safety case lifecycle management guidance note
Guidance explains regulatory management of facility safety cases from design notification and operator registration through submission, acceptance, revision and withdrawal. It distinguishes internal management of change from changes requiring formal revision, addresses five-yearly reviews and validation-scope agreements, and emphasises maintaining an accurate, continually reviewed account of safety arrangements.
- 202518 Dec
BSEE: Anchor-handling causes damage to subsea equipment and triggers gas release
An anchor wire snagged a subsea well during recovery by a dive support vessel, subsequently detaching an annulus valve and releasing gas. The flash summarises BSEE findings on inadequate planning, coordination and emergency preparation, with recommendations for consideration covering readiness checks, change management, communication and current-aware anchor-handling plans.
- 202510 Dec
Critical task analysis information paper
Explains how critical task analysis supports identification and management of human error risks in offshore petroleum operations. Describes hierarchical decomposition into goals, operations and plans, followed by tabular error analysis and risk assessment. Outlines stakeholder engagement, piloting, iteration and documentation when introducing the methodology.
- 20259 Dec
Human error risk reduction to ALARP information paper
This information paper suggests an ALARP-based approach to human error risk in the Australian offshore petroleum industry. It treats error as a barrier-defeating factor and outlines critical-task identification, error classification, performance-shaping factor analysis and control evaluation, distinguishing prevention from recovery and consequence mitigation.
- 20259 Dec
Safety culture information paper
Explains NOPSEMA’s non-mandatory safety culture model, linking executive commitment and behaviour with leadership practices, organisational systems, working environments and safety outcomes. Drawing on Schein’s cultural layers, it uses contrasting fictional petroleum companies to illustrate how shared assumptions shape reporting behaviour and the effectiveness of safety improvement initiatives.
- 202525 Nov
Safety management system guidance note
Guidance on integrating safety management systems with the offshore petroleum safety-case regime. It addresses control effectiveness, workforce competence, work authorisation, change management and continual improvement. Performance standards, monitoring and review underpin assurance, alongside organisational commitment and management of both major accident and occupational risks, including psychosocial hazards.
- 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.
- 202521 Oct
Risk assessment guidance note
Guidance for offshore petroleum operators on assessing major accident and wider health and safety risks. It explains qualitative, semi-quantitative and quantitative methods, likelihood and consequence analysis, control reliability and uncertainty. Safety-case documentation, ALARP arguments, workforce participation, assessment review and quality assurance underpin selection of appropriate controls.
- 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.
- 202519 Aug
Operational risk assessment guidance note
Guidance for offshore oil and gas operators on assessing temporary impairment of safety-critical controls and operation outside design limits. It explains hazard identification, qualitative or semi-quantitative risk evaluation, mitigation assurance, cumulative risk, responsibilities and restoration periods. Assessment must not justify predetermined continuation decisions or substitute for managing permanent changes.
- 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.
- 202512 Jun
Diving Guidelines - Diving Safety Management Systems and Diving Project Plans
Guidance for preparing diving safety management systems and project-specific diving plans under OPGGS and OEI regulations. It addresses hazard assessment, operational procedures, competence, maintenance, workforce consultation and change management. Emergency provisions include diving bell rescue and evacuation of saturation divers while maintaining pressure, alongside monitoring, investigation and audit requirements.
- 202512 Jun
Replacement of a registered operator for a facility or pipeline guidance note
This guidance explains how facility owners and titleholders nominate a replacement operator and how NOPSEMA registers the change. It sets out operator-specific safety case requirements, transitional arrangements, validation scope and submission timing, including the sequence by which the new safety case takes effect.
- 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.
- 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.
- 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.
- 202417 Dec
High potential: spontaneous opening of hydraulic release shackle (HRS) pin
A hydraulic release shackle opened during vessel lifting operations, dropping approximately 4–5 metres and remaining suspended by its hydraulic hose. Nobody was harmed. Subsequent checks identified damage to two shackles. Findings highlighted an unassessed change to the hydraulic set-up, procedural non-compliance and inadequate communication; lessons emphasise change control and stopping work when uncertain.
- 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.
- 202425 Sep
Tampering with approved safety devices
A client inspection found a homemade clamp holding open a self-closing valve on a vessel’s lubricating oil storage tank. Installed to save time, the modification had escaped routine checks. The flash highlights safety-device integrity, adherence to procedures and proper approval or management of change for equipment modifications.
- 202429 Aug
Dropped object during cable trans-spooling
During cable trans-spooling ashore, a failed connection bolt released a 5.7 kg roller, which fell 8 m and struck a worker’s shoulder. The flash examines inadequate risk assessments, missing secondary retention, changed offloading arrangements and uncommunicated cable wax, emphasising management of change and better communication.
- 202418 Jun
Dropped welding fume extraction hood
During vessel pipelay, a 215 kg welding fume extraction hood fell and struck a crew member. Misunderstood installation drawings left it supported by a single bolt, which cracked and sheared under dynamic loading. The flash highlights modification control, securing arrangements and omissions from DROPS registers and inspections.
- 20243 Jun
Stored energy – dislodged pin causes injury
A worker suffered a forehead laceration when a stuck securing pin was forced out using a hydraulic jack during structure removal. The flash examines unassessed changes to the work method and exposure to stored energy. Lessons include stopping and reassessing changed tasks, with pin cages or catchers proposed as an engineering solution.
- 202422 May
Hand and finger injuries... Two recent incidents
This safety flash describes two hand injuries: a fractured little finger caused by movement of a moonpool door ram on a flat pallet, and a cut from a sharp-edged ceiling plate. Lessons address thorough task assessment, reassessment when work changes, stopping unsafe work and wearing protective gloves.
- 202430 Apr
Near miss: dislodged grating with potential fall to sea
A vessel welder recovered without injury after GRP grating tipped and fell 5.5 m into the sea. Incorrectly secured clips, missing design clips and an unnoticed overhang were identified. The flash describes maintenance and checklist changes, future DROPS surveys, design guidance and approval requirements for grating modifications.
- 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.
- 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.
- 202427 Mar
Implosion of chemical tank
A chemical tank on a vessel imploded after pumping created a vacuum with its manual air inlet valve unopened. Around two cubic metres of monoethylene glycol spilled onto the deck and into the sea; nobody was injured. The flash examines unfamiliar replacement equipment, supplier assurance, documentation, familiarisation and management of change.
- 202427 Mar
Person injured when chain hoist container failed at securing point
A chain-hoist container weighing approximately 30 kg fell around 0.8 m onto a crew member during pipelaying clamp adjustment, causing bruising and contusion. The flash identifies an inadequately engineered modification, omitted secondary retention and incomplete inspection detail, and calls for change management, improved maintenance inspections and secondary retention where required.
- 202419 Mar
Person struck and injured during lifting operations
During spar decommissioning, a partially attached fire water pump skid came free on a second lifting attempt and struck a nitrogen vessel previously cut 95% loose. The vessel struck a worker. The flash identifies unknown welds, inadequate work and change controls, and ignored crew concerns, emphasising preparation, listening and reassessment.
- 202428 Feb
When to submit a proposed revision of an environment plan guideline
NOPSEMA guidance explains when petroleum titleholders must submit revised environment plans. It distinguishes new activities, significant modifications, new stages, changed environmental impacts or risks, and titleholder changes. It also addresses regulator-requested and five-year revisions, acceptance requirements, documented change assessments and compliance monitoring.
- 202427 Feb
Pipeline End Manifold yoke dropped from 45° position
A vessel rigging team released one restraint while adjusting a pipeline end manifold yoke held at 45°, causing the opposite cargo strap to fail and the yoke to fall horizontally. Two nearby workers were uninjured. Learning addresses unsuitable straps, engineered securing, task risk assessment and management of change.
- 20249 Jan
Diver in the bell hit by falling object
A diver sustained minor head and shoulder injuries when a partially frozen water bottle fell into a diving bell transfer lock after its handle broke. Bottles were being used for cooling without a change risk assessment. Actions included updating change management and risk assessment, and starting arrangements for a bell chiller.
- 202318 Dec
Line of fire near miss during lifting operations
A banksman narrowly avoided a structure being landed on a vessel’s back deck; an adjacent container was damaged. Inadequately spaced bumper bars allowed load rotation and were wrongly relied upon for personnel protection. The flash discusses exclusion zones, unassessed changes and differences between planned and actual work.
- 202311 Dec
Foundation Food Group Fatal Chemical Release
Investigation of a fatal liquid nitrogen overflow at Foundation Food Group’s poultry plant. A deformed bubbler tube disabled freezer level control and overflow protection, producing an oxygen-deficient room atmosphere. The report examines design dependencies, missing monitoring and ventilation, emergency preparedness, process safety management and regulatory gaps.
- 20236 Dec
Didion Milling Company Explosion and Fire
CSB investigates fatal combustible corn dust explosions at Didion’s Cambria mill. It examines propagation through interconnected dust collectors and pneumatic conveying systems, secondary explosions and building collapses. Comparative mill teardown, dust testing and explosion modelling support analysis of deficient safeguards, change management, housekeeping, emergency preparedness and regulatory oversight.
- 2023Dec
Overfill of vapour recovery units
HSE warns that a gasoline overfill exposed dependence between a vapour recovery unit’s process controls and overfill protection, resulting in loss of containment. The notice calls for risk assessment, physical verification, inspection, maintenance and testing of safety functions, with independent safeguards and control-system modifications where required, managed through change procedures.
- 202321 Nov
EI 158 Fatality Failure to Use Safety
An offshore worker died when surface casing failed during pressure testing supplied by a high-pressure well. The explosion involved pressure release without signs of ignition. BSEE identifies omitted pressure safeguards and deficiencies in planning and change management, and recommends operators consider equipment compatibility checks, gauge training and improved hazard assessment.
- 202315 Aug
Caught between: Unplanned movement of equipment leads to severe injuries
A mechanic suffered severe injuries when moving hydraulic hoses tipped a three-tonne hose saddle towards a container door, trapping him. The flash examines instability, absent securing and shortcomings in change management and work coordination during maintenance. Actions address equipment stability, sea-fastening, work authorisation and toolbox participation.
- 202315 Aug
LTI – Person fractured pelvis in a fall from a ladder
A crew member fractured his pelvis after slipping from a temporary cargo-hold access ladder aboard a cargo vessel. The flash examines blocked permanent access, an unprotected platform edge, absent risk assessment and change management, and unchallenged subcontractor standards. Actions address contractor assurance, supervision, stop-work authority and safe access.
- 202314 Aug
MODU mooring systems in cyclonic conditions information paper
This information paper examines cyclonic mooring risks for mobile offshore drilling units. It discusses site-specific design return periods, met-ocean and seabed inputs, component degradation, installation assurance and change management. Operational guidance covers line-tension management, inspection performance standards, emergency preparedness and consideration of position monitoring during cyclone evacuation.
- 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.
- 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.
- 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.
- 202316 May
Adaptation and Modification of Tool Results in Injury
An offshore worker sustained a hand laceration requiring sutures while shortening a combination wrench with a hacksaw for hydraulic-line installation. The alert examines unavailable suitable tools, unapproved modification and failure to consult a supervisor. Corrective actions address close-radius tools, pre-job hazard assessment and communicating restrictions on altering manufacturers’ equipment.
- 20233 May
Uncontrolled movement of spreader bar
During preparations for subsea spool deployment, a spreader bar rotated and fell onto the deck and spool as rigging was raised after sea-fastening removal. A nearby rigger moved clear; nobody was injured. The flash identifies shortcomings in hazard communication, lifting sequence, change management and design risk review, and recommends task briefings and debriefs.
- 2023Apr
Noise and Vibration
Inspection guidance for assessing offshore dutyholders’ management of occupational noise and hand-arm vibration. It combines inspection questions, performance scoring and enforcement expectations with discussion of engineering controls, tool selection, exposure-time management, hearing protection and health surveillance. It distinguishes hearing protection from noise control and addresses sustained regulatory compliance.
- 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.
- 202313 Mar
Lift bag near miss
A lift bag escaped its intended rigging during spool over-boarding and was arrested by contingency rigging. The flash examines inappropriate attachment, undocumented rigging changes, unclear diver communications and task-generic procedures. Lessons emphasise single-person rigging accountability, task-specific instructions, reduced multitasking and thorough communication during personnel changes.
- 20237 Mar
Investigation of Subsea Leak Identifies the Use of Materials Susceptible to Hydrogen Embrittlement (update)
A subsea jumper leak released approximately 479 barrels of oil into the Gulf of Mexico. Investigation attributed fractured Inconel 718 flange studs to hydrogen embrittlement and identified procurement, quality assurance and change-management gaps. The alert recommends operators consider metallurgical evaluation, fastener torque documentation and improved subsea leak alarm monitoring.
- 202311 Jan
Umbilical management – near miss
A diver’s umbilical became trapped when a pipeline rolled during crane-assisted removal of sleeper supports beneath a repair spool. The diver freed it and was unharmed. The flash identifies missing removal procedures, unrecognised umbilical hazards and absent change management, recommending a removal procedure and crew review.
- 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.
- 202223 Nov
MAIB: Flooding and sinking of the survey workboat Bella
This safety flash summarises MAIB findings on Bella’s sinking during hydrographic surveying near Lynmouth. Survey equipment modifications reduced forward freeboard, while inadequate buoyancy allowed swamping to overwhelm the boat. It highlights certification and safety-management shortcomings, alongside the crew’s successful abandonment using personal flotation devices and a life raft.
- 202226 Sep
MAIB: Capsize and sinking of fishing vessel Joanna C – vessel stability
This safety flash summarises MAIB findings on Joanna C’s fatal capsize while recovering scallop dredges snagged on a potting line. Through-life modifications had reduced stability, with assessment left unfinished. It also examines the liferaft’s failure to inflate and highlights stability implications of modifications and float-free lifesaving arrangements.
- 20227 Sep
Temporary Equipment as a Potential Source of Ignition on Offshore Facilities
BSEE describes three examples of temporary equipment unsuitable for hazardous areas on offshore facilities: a diesel air compressor, hydraulic power pack and portable fan. The alert recommends considering equipment checks, ignition controls, management of change, pre-startup review and documented risk assessment throughout installation, use and removal.
- 20224 Jul
American P&I Club: Extreme bollard pull
A container vessel’s four bow lines overloaded a single dock bollard through their self-tensioning winches after crane obstruction prompted a departure from normal mooring practice. The bollard failed, but spring lines limited vessel movement and nobody was injured. The flash highlights bollard capacity checks and assessment of changed mooring arrangements.
- 202222 Jun
Capsize and sinking of scallop dredger Joanna C with loss of 2 lives
Investigation of Joanna C’s fatal capsize south of Newhaven during scallop dredge recovery. It examines stability degraded by modifications, unfinished inclining-experiment analysis and regulatory oversight. Liferaft buoyancy and inflation-force testing explains failed automatic inflation, while survival analysis addresses flotation loss, delayed beacon activation and escape from the sinking vessel.
- 202222 Jun
Capsize and sinking of whelk potter Nicola Faith with loss of 3 lives
Investigation of Nicola Faith’s fatal capsize in Colwyn Bay examines vessel modifications, combined catch and pot loading, and survival arrangements. Stability testing and modelling underpin the conclusion that loading almost certainly caused sudden instability. The report also assesses regulatory gaps, mandatory training, emergency beacons and personal flotation.
- 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.
- 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.
- 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.
- 202211 Mar
MSF: Foreign object in eye
A seafarer sustained an eye injury while chipping paint and required hospital removal of debris after unsuccessful onboard treatment. The flash identifies unsuitable eyewear following a task change and inadequate risk assessment. Subsequent actions included reviewing onboard assessments and sourcing combined safety glasses and goggles.
- 202228 Jan
Engine room fire on a ferry
This flash examines a ferry engine-room fire involving thermal oil circulation pump bearing failures and ineffective water-mist suppression. It describes loss of power and propulsion, successful CO2 extinguishment, and lessons on emergency supplies, contingency planning, management of change, thermal imaging and the risk of reignition after re-entry.
- 202125 Nov
Dropped object: Dislodged flex-joint laydown tool component
An 85 kg load-ring half plate fell about 1.8 m to deck during flex-joint laydown-tool removal on a tilted J-Lay Tower. Nobody was injured. Manual removal replaced the approved crane-assisted method without risk assessment. The flash emphasises procedural compliance, management of change and stopping work when uncertain.
- 202118 Nov
Shackle failure during over-boarding of pennant wire and ballast chain
A shackle failed while ballast chain and pennant wire were being over-boarded from an anchor-handling winch. Released chain damaged nearby equipment, with nobody harmed. Evidence suggested the shackle nut became trapped in a chain link. The account identifies shortcomings in connection arrangements, maintenance, risk assessment and management-of-change documentation.
- 202128 Oct
Unexpected movement of conductor during diver dredging operations
During diver dredging before conductor cutting, a conductor toppled at a severance point, leaving an umbilical spanning between conductors. Crane restraint and vessel manoeuvring enabled release without injury or damage. The flash identifies incomplete task information and recommends conductor restraint, data verification, revised risk assessment and improved change management.
- 202115 Oct
Line of fire near miss – almost a head injury
During cable trans-spooling between a vessel and barge, a tensioned messenger rope climbed out of a chute and struck a crew member’s helmet. A similar near miss followed three weeks later. Lessons address differing spooling speeds, cable tension, communication, change assessment, stopping work and enclosing chutes.
- 202114 Sep
BSEE Identifies Dropped Object Hazards during Risk Based Inspections
BSEE summarises risk-based inspections addressing dropped-object hazards in offshore production and well operations. Findings highlight weaknesses in prevention programmes, hazard hunts, training, lifting analyses and restricted access. Operators and contractors are encouraged to consider targeted inspections, documented findings, dedicated training and management-of-change triggers for new equipment or structures.
- 202119 Aug
NOPSEMA: Person injured in chain hoist incident
An offshore lifting incident injured one worker when a monorail hoist dropped a 500 kg piping spool, including ancillaries. NOPSEMA’s preliminary findings identified unsuitable end stops and trolley width, modification outside change management, and failure to follow the lift plan. Recommendations address competent inspection, equipment selection and restrictions on non-vertical lifting.
- 202127 Apr
Update to SF 08/21: Fatality – person crushed when secured material fell on him
Updated safety flash describing a fatal crushing during loose lifting gear inspection. Manipulation of a ratchet strap released vertically stored metal plates, trapping the inspection team leader against a drilling bail rack framework. Actions address changing task risks, sea-fastening security, safer storage, stop-work authority and contractor integration.
- 202130 Mar
Dropped object – Steel deck plate falls from pipelay tower
A steel deck plate fell 9 m during pipelay tower inspection on a vessel in dry dock. Corroded, incorrectly specified bolts and inadequate support were identified in an undocumented modification. Nobody was hurt; barriers protected the drop zone. The flash recommends routine inspection of elevated plates and fixings, and controlled equipment modifications.
- 202125 Mar
Inadquate operation of circuit breaker
A maintenance worker checking a compressor breaker during an annual inspection disengaged it, triggering alarms and facility downtime without injury or equipment damage. The alert examines ambiguous switchboard labels, indicator colours and missing procedures, and asks operators to consider training, updated documentation, pre-job meetings and protective button coverings.
- 202117 Mar
Crane wire parted during offshore operations
A vessel crane wire failed while overboarding a concrete mattress for a pipeline crossing, dropping the load before it entered the water. The flash examines unresolved magnetic rope testing results, misunderstood operational limits and absent change management, and calls for better shore–vessel communication and lift routing away from existing pipelines.
- 20214 Mar
Line of fire: deck tugger wire failure
During back-fill plough recovery, a chain sling failed under increasing tension and recoiling rigging narrowly missed deck personnel. The flash identifies unclear communication of a changed hauling method, uncertain operational responsibilities and failure to follow safe-zone requirements. Actions address toolbox talks, procedural compliance, management of change and shared understanding of tensioned-line hazards.
- 202123 Feb
Inappropriate use of pneumatic line thrower for mooring line
A vessel’s crew used a pneumatic line thrower during mooring after difficulty getting a heaving line ashore. Two projectiles disappeared and a warehouse window was broken approximately 100 metres from the vessel. The flash identifies shortcomings in instructions, risk assessment and communication, and emphasises managing changed plans, toolbox talks and stopping unsafe work.
- 202111 Feb
Crane whip line parted during hook stop testing
During auxiliary winch hook-stop testing, uncontrolled hoisting caused a headache ball to strike the crane jib, snap the wire and fall with the rigging to deck. Corroded speed encoders and poor wire condition were identified. The flash addresses rope examination, encoder maintenance, management of change and start-up risk assessment.
- 20212 Feb
COVID-19 Improper Risk Management
A vessel sailed while a repeat COVID-19 PCR result was pending, contrary to approved crew-change mitigations. The subsequent positive result required 14 days of onboard isolation, with no further infections reported. The flash addresses formal change approval, obtaining test results before sailing, medical fitness and access to adequate care.
- 202121 Jan
Risk-Based Inspections of Subsea Leak Detection Technology Reveals Gaps in System Processes
BSEE reviews three subsea oil leaks and inspection findings showing weaknesses in leak-detection procedures and management processes. Operators and contractors are asked to consider clearer alarm response responsibilities, personnel training, system testing, configuration change control and ROV surveys. The alert emphasises investigating abnormal flow and learning from previous detection failures.
- 202119 Jan
Well Control - Issue 6
An offshore well-control inspection guide using questions, model answers and success criteria to assess operational arrangements. It examines conventional, high-pressure high-temperature and managed pressure drilling, including BOP assurance, kick detection, hydraulic modelling, fingerprinting, pressure relief, contingency procedures and crew training. Inspection scoring supports subsequent regulatory intervention planning.
- 20215 Jan
Secured material fell against crewman causing injury
A crewman checking preparations for rough weather was pinned beneath stored sheet metal and wood after both securing straps disengaged during adjustment and vessel movement toppled the rack. The flash discusses safer storage and securing, risk assessment, assistance when working alone, and toolbox talks addressing changes during routine tasks.
- 20206 Dec
Injury caused by closing fire flap
A crewman sustained a left-wrist wound when a fire damper closed during improvised filling of an expansion tank through ventilation trunking. The flash contrasts this method with the approved portable-pump arrangement and highlights non-routine risk assessment, adherence to procedures and management of change where approved systems are not functional.
- 202026 Nov
Rigging failure – Clump weight dropped to seabed
A weather buoy’s 2.6-tonne clump weight dropped to the seabed after a chain link failed during deployment. The selected weight exceeded the design’s 450 kg allowance, and the chain was unsuitable for lifting. The flash recommends formal management of change, thorough lift planning and checks of rigging certification and suitability.
- 20209 Oct
Oil production riser gas ignition
During recovery of an oil production riser at an FPSO, hot-work sparks ignited residual gas in the bore. A slit introduced to address another hazard allowed air ingress and a spark path. The flash highlights missed change-related risks in hazard assessments; no injuries or equipment damage were reported.
- 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.
- 202028 Sep
US Coast Guard: Addressing hazardous area electrical issues
This flash summarises US Coast Guard findings concerning certified electrical installations in vessel hazardous areas. Incorrect installation, missing or degraded components and unfamiliarity with standards compromised protection. The alert strongly recommends IEC-aligned training, periodic inspection and maintenance by competent personnel, competent repairs and regulatory approval of system modifications.
- 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.