Control
Operating and Work Procedures
Development, use and assurance of operating/work instructions.
Newest 100 Documents
All 1,662 in search- 2026Sep
Shell Polymers Furnace Explosion and Fire — Furnace Explosion and Fire at Shell Polymers
Investigates the June 2025 furnace explosion and fire at Shell Polymers Monaca following coke-trap cleaning. Inadvertent opening of isolation valves allowed cracked gas to enter the firebox and ignite. The report examines reliance on administrative safeguards, safety instrumented system bypasses, alarm suppression and confusing valve interfaces, recommending engineered protection and improved interface design.
- 202619 Aug
Segregate Pyrotechnics and Verify Flare Type Before Emergency Drills
A worker suffered second-degree burns after mistakenly activating a parachute flare rather than a handheld flare during a fast rescue craft drill. The alert examines mixed storage, inadequate planning and training, and procedural non-adherence, recommending consideration of improved segregation, labelling, task-specific controls and alternatives to offshore pyrotechnic expending.
- 202612 Aug
Control Portable Electronic Device Use to Prevent Ignition Hazards Offshore
This alert describes inspection findings involving unauthorised cellphone use during offshore wireline operations and unrated electronic devices in a hazardous area without a hot work permit. It recommends that operators and contractors consider intrinsic-safety certification, conditional permit requirements, policy reviews and reinforcement of device restrictions during orientations.
- 202612 Aug
Crane Failure Highlights Crane Inspection Gaps
Two platform crane incidents involved failed sheave bearings, a falling boom and a dropped cable and load block. Inspection gaps included omitted pin removal and inadequate lubrication checks. The alert recommends considering revised inspection criteria, scheduled inspections, training to recognise mechanical distress and lift planning around vessel interfaces.
- 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.
- 20261 Jul
Inspect A2B Systems and Wire Rope Terminations to Prevent Crane Hazards
A lift boat crane incident involved a detached anti–two-block weight, corroded wire rope and falling components. Recoiling rope struck a nearby diver, causing minor injuries. The alert recommends considering termination maintenance, pre-use and periodic inspections, adjusted replacement intervals in corrosive environments, and competence assurance under API RP 2D.
- 20261 Jul
Mechanical Failure of LACT Pump Caused Fire
An offshore production facility fire followed LACT charge-pump misalignment after motor replacement. Excessive vibration loosened casing fasteners, allowing oil leakage; coupling failure caused further damage. The alert identifies omitted angular alignment and incorrect bolt torques, and recommends manufacturer-compliant installation, personnel training, review of post-installation surveillance and investigation of abnormal operation.
- 20261 Jul
Verify Riser Fin Retention Systems Before Prompts Riser-Handling Operations
Two thermoplastic fins detached during slick-riser handling, creating dropped-object near misses. Findings identified inadequate retention tension, omitted torque verification and 48-hour re-torque, deficient refurbishment and inconsistent checklists. BSEE recommends manufacturer-specified securing checks, design improvements, procedural discipline, vendor acceptance assurance and dropped-object risk assessment.
- 202625 Jun
Serious injury to a crew member on board the scallop dredger Jacoba (BM77)
Investigation into serious crushing injuries aboard Jacoba during scallop dredging in the English Channel. A winch-operated main beam was lowered while a deckhand worked beneath it to clear snagged gear. The report examines inadequate task-specific risk assessments, snag-clearing procedures, familiarisation, crew certification and oversight, and recommends improvements to fleet safety management.
- 202621 May
AW139 Tail Rotor Duplex Bearing Failure Discovered During Maintenance
AAIB investigates a tail rotor duplex bearing failure on AW139 G-CIMU, discovered during maintenance at Norwich Airport after offshore passenger operations. Forensic examination could not establish the initiating cause. Rig testing discounted removal damage, while flight-data analysis identified pedal-position trends. The report examines inspection limits, condition monitoring and critical-part regulatory assurance.
- 202614 May
Machinery damaged through improper maintenance technique
An offshore vessel audit identified a fuel oil purifier that failed to self-discharge. Investigation found incompatible component swaps and bowl damage from improper dismantling without specified tools. The flash highlights adherence to manufacturer instructions, compatible genuine parts, planned maintenance intervals, repair records and stop-work authority.
- 20266 May
Catastrophic engine failure and subsequent fire on board the site investigation vessel Kommandor Susan
Investigates a diesel generator failure and engine-room fire aboard Kommandor Susan during sea trials in the Firth of Forth. The report links premature bearing wear to substitute components and inappropriate extended service intervals, examines contractor oversight, and describes successful firefighting alongside emergency anchoring difficulties caused by dependence on electrical power.
- 202628 Apr
Diver entanglement – uncontrolled equipment in the water column
During shallow-water welding, a diver’s bail-out regulator became entangled in a rope supporting a rubber mat and welding rods. Swell moved the suspended items uncontrollably. A stand-by diver freed him within the planned diving time. The flash highlights loose-rope avoidance, tool positioning and possible use of lockable carabiners.
- 202628 Apr
Unsecured sheave pin fell from crane
A 1.3 kg sheave pin fell from a third-party crawler crane and was found on deck, with no injuries. The flash identifies incomplete assembly documentation, an undocumented configuration agreement and absent secondary retention. Lessons address configuration records, additional securing safeguards and responsibility for subcontracted equipment risks.
- 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.
- 202615 Apr
Unauthorised boarding and theft from vessel at anchor
This safety flash describes theft from crew cabins after unauthorised night-time boarding of an anchored vessel. It identifies inadequate vigilance, unsecured accommodation access and insufficient deck monitoring. Lessons address watchkeeping, locked non-emergency doors, security rounds, Ship Security Plan compliance, crew briefings and security drills.
- 202631 Mar
Source control planning and procedures information paper
This information paper sets out regulatory expectations for offshore loss-of-well-control preparedness across environment plans, well operations management plans and safety cases. It covers capping-stack selection and deployment, relief-well design and dynamic kill analysis, plume modelling, subsea dispersant supply, water-column monitoring, response-time modelling, coordinated operations and readiness exercises.
- 202631 Mar
Well integrity control measures and performance standards guidance note
Guidance for developing and implementing well operation management plans addresses selection, assessment and assurance of well-integrity controls throughout the lifecycle. It explains links between risk assessment and measurable performance standards, periodic effectiveness reviews, functional testing, procedural assurance, contingency measures and relief-well planning, with quality checks for documented control performance.
- 202626 Mar
Fatal accident to a crew member on board the roll-on/roll-off cargo vessel Laureline
Investigates a crew member’s fatal crushing between a reversing trailer and Laureline’s structure during cargo operations at Purfleet. CCTV review and scene inspection informed analysis of driver–crew communication, danger-zone definitions, training and supervision. The report examines procedural weaknesses, subsequent safety actions and recommendations for an industry vehicle-deck code of practice.
- 202624 Mar
BSEE: Crane incident leads to serious facial injuries
This flash summarises BSEE findings on a lifting pin failure during well abandonment aboard a lift boat, resulting in serious facial injuries. It describes stuck casing, excessive loading, incorrect sling positioning and unsuitable procedures, with recommendations addressing free loads, rigging plans, safe working loads and stop-work authority.
- 202624 Mar
MSF: High potential near miss during FRC maintenance
During sling replacement aboard a vessel, a fast rescue craft slipped from its davit cradle. Two crew members jumped into the sea and were recovered unharmed. The flash describes inadequate securing, a failed bowsing-line carabiner and gaps in work planning, including missing procedures, risk assessment and permit authorisation.
- 202611 Mar
Loss of propulsion in heavy weather experienced by the passenger vessel Spirit of Discovery, leading to over 100 injuries and one fatality
Investigation of Spirit of Discovery’s repeated propulsion losses in heavy weather in the Bay of Biscay. It examines pod overspeed protection, automatic pod parking, weather routing, furniture securing and medical response. Violent vessel motion injured 115 passengers; one passenger sustained a spinal injury and died four days later.
- 20263 Mar
Cook temporarily trapped in freezer
A vessel’s cook became trapped in a walk-in freezer when the unsecured door closed during adverse weather and the internal release button was inoperable following moisture ingress. Crew opened the door externally without injury. Actions included weekly maintenance inspections, greasing the release mechanism, revised entry procedures and crew training.
- 20263 Mar
W2W gangway bumper damaged during demonstration
A walk-to-work gangway bumper broke off during an emergency-retraction demonstration while connected to an offshore wind turbine transition piece. Vessel movement during an approximately one-second uncompensated delay overloaded the bolts. Nobody was harmed. Actions included crew refamiliarisation, revised demonstration procedures and manufacturer evaluation of a possible software revision requiring class approval.
- 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.
- 202626 Feb
Dow Louisiana Operations Explosions
Investigation of the Dow Plaquemine explosion examines work lights left inside a reflux drum during turnaround. Degraded light debris punctured a rupture disc, admitting ethylene oxide into air-containing relief piping. The report analyses vessel closure practices, loss of nitrogen inerting, inadequate monitoring and relief routing that enabled propagation into the drum.
- 202623 Feb
PEMEX Deer Park Chemical Release
CSB investigation of a fatal hydrogen sulphide release during refinery maintenance in Deer Park, Texas. Workers opened the wrong flange on active piping. The report examines equipment identification, permit scope and hold points, interacting maintenance operations, contractor reassignment and operational discipline, recommending clearer marking and work authorisation arrangements.
- 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.
- 202611 Feb
Collision between the bulk carrier Polesie and the general cargo ship Verity resulting in the sinking of Verity and loss of five lives
Investigation of the German Bight collision between Polesie and Verity, which rapidly sank with five fatalities. It examines incremental collision-avoidance manoeuvres, navigation displays, late vessel traffic service intervention and duplex radio limitations, alongside flooding, search and rescue, and the constraints imposed by absent voyage data recorder evidence.
- 20266 Feb
BSEE Safety Alert 514 - Verify Megger Testing and Termination Prep to Prevent Seawater Pump Motor Fires
A seawater pump motor fire followed termination repairs. Findings identified insulation testing at a lower voltage than required, resistance below the work-pack threshold and inadequate semiconductor-layer preparation. BSEE recommends considering adherence to repair instructions, verification of test arrangements and results, correctly rated testers and worker understanding of resistance units.
- 20265 Feb
Collision between the crude oil tanker Apache and the stern trawler Serinah (GH 116)
Investigates the collision of Apache and Serinah in the Firth of Clyde and the trawler’s subsequent flooding and sinking. Examines inadequate avoiding action, watchkeeping competence, navigation equipment, traffic monitoring and assistance after collision. All three fishing crew survived uninjured; recommendations address navigational training and understanding fishing vessel behaviour.
- 20264 Feb
BSEE Safety Alert 512 - Crane Incident During Well Abandonment Operations Injures Worker, Reveals Safety Gaps
A lifting pin failed and struck a worker during crane-assisted casing removal for well abandonment. Findings identify obstructed casing, excessive loading, misplaced sling connections and unsuitable procedures. Recommendations address free loads, correct equipment and rigging, accurate safe working loads, hazard awareness and stop-work authority.
- 202622 Jan
Mechanic got burns due to fire in portable generator
A marine mechanic sustained minor right-arm burns after spilled petrol ignited during portable-generator refuelling at a dock workshop. Dragging the generator produced a friction spark. The flash identifies missing rubber bushings, absent procedures and risk assessment, inadequate maintenance and housekeeping, and difficult access to fire extinguishers.
- 202622 Jan
Petrol driven equipment left stored in an emergency generator room
A vessel safety round identified a petrol-containing snowblower stored in the emergency generator room, creating fire and explosion risks and obstructing access to critical equipment. The equipment was relocated. The flash recommends designated storage for flammables and keeping machinery spaces clear, with storage procedures and inspections identified for review.
- 202622 Jan
Some positive findings and good practices
This flash presents four positive marine safety observations: thorough safety-zone entry checks on a PSV, a fabricated mesh guard protecting an open mud-tank hatch during ventilation, simulator-based officer training in Papua New Guinea, and crew-led deck upkeep. It reinforces procedural discipline, hatch protection, competence development and maintenance beyond dry-dock schedules.
- 202622 Jan
Umbilical support frame made contact with passing vehicle on public road
An umbilical support frame wing dropped during public-road transport and struck a passing vehicle. The flash identifies missing transport brackets, assumptions about retaining pins and absent securing instructions. Actions address drawing conformity, equipment marking, mobilisation and de-mobilisation verification, planning meetings and clear instructions for those moving specialist equipment.
- 202612 Jan
LTI – back injury
An Able Seaman suffered a lower-back injury while lowering a crew transfer vessel’s gangway onto the quay. The flash examines lone manual handling, crane-position constraints, uncertain gangway weight and inadequate procedural risk controls. Lessons include ideally using two people when mechanical aids cannot be used, reviewing assessments and verifying gangway weights.
- 2026Jan
Well Operations
An inspection guide presenting compliance questions for well operations under Subpart G, with regulatory authorities and enforcement codes. It covers casing and liner integrity, surface and subsea blowout preventer configuration, pressure and function testing, maintenance and records, alongside specific requirements for coiled tubing and snubbing systems.
- 202518 Dec
Dropped object – Bailout cylinder inside diving bell
During saturation diving preparations aboard a vessel, an unsecured bailout set fell approximately 2.5 metres through the bell opening, striking the Transfer Under Pressure door. Nobody was injured; the cylinder was damaged. The flash identifies deficient securing and checks, and records replacement of S-hooks, formal instructions, revised hazard analyses and retraining.
- 202518 Dec
Two Walk-to-Work gangway incidents
Two related Walk-to-Work gangway incidents occurred during offshore wind personnel transfers. Hydraulic stiction caused uncontrolled slewing and a collision with the vessel crane. Subsequent modifications introduced an automation logic error that prevented retraction during connection preparation. The flash describes hydraulic adjustments, revised operating procedures and manufacturer testing; neither incident caused injury.
- 202517 Dec
Capsize and foundering of the prawn trawler Odyssey (FR 70)
Investigation of Odyssey’s capsize during net recovery in the North Sea. Wash water accumulated on the shelter deck, with a tonnage valve likely obstructed, causing loss of stability. Stability modelling, pump controls, drainage arrangements and emergency preparedness are examined. All six crew abandoned to a liferaft and were rescued uninjured.
- 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.
- 20254 Dec
Dropped pallet during cargo transfer
A plastic pallet carrying lubricant drums tipped and fell during a barge-to-vessel lift at an anchorage, rupturing drums and spilling oil on deck without injury or structural damage. The flash examines inadequate securing, procedural non-compliance and crew coordination, and describes improved load checks, secondary securing, toolbox meetings and supervision.
- 20254 Dec
Fire hazard: missing splash tapes on fuel hose connections
This safety flash describes missing splash tapes on engine fuel hose connections in newly delivered and older vessels. It explains their role in preventing fuel spray reaching hot surfaces, identifies commissioning omissions and failures to reinstall tapes after maintenance, and stresses acceptance checks and restoration of safety details.
- 20254 Dec
Vessel ran aground
A vessel grounded in a narrow channel at low tide during a short voyage, then refloated without damage, injury or pollution. The flash examines shortcomings in passage planning and watchkeeping, including bridge distractions and overconfidence in familiar waters. Lessons emphasise approved passage plans, briefings, tidal knowledge and under-keel clearance.
- 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.
- 2025Nov
Food Hygiene Inspection Guide
An offshore food hygiene inspection guide for regulatory inspectors, linking legal requirements with dutyholder performance ratings and enforcement expectations. Its Plan, Do, Check, Act checklist examines HACCP arrangements, catering facilities, temperature monitoring, cross-contamination, cleaning, maintenance, staff competence and verification of food safety management.
- 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.
- 2025Nov
Water Management
Inspection guidance for assessing offshore dutyholders’ potable-water arrangements and legionella controls. It covers system-wide risk assessment, written control schemes, hose disinfection, biocide dosing and chemical and microbiological monitoring. Success criteria, performance scoring and enforcement expectations support inspectors’ judgements on legal compliance and occupational health protection.
- 202527 Oct
Japan Transport Safety Board: two confined space fatalities
An IMCA flash summarises a Japanese bulk-carrier incident in which two stevedores collapsed during unloading; one died and one was seriously injured. Low oxygen and elevated carbon dioxide were likely linked to palm kernel shell fermentation. It highlights absent atmospheric testing, inadequate work controls and recommendations for training and cargo risk profiling.
- 202516 Oct
Fatal injury to a recreational diver following contact with the motor vessel Karin operating as a recreational dive support vessel
Investigates a recreational diver’s fatal propeller strike during a drift decompression stop in Scapa Flow. Examines Karin’s obstructed forward visibility, ineffective lookout, marker-buoy attachment, vessel coordination and absent documented safety arrangements. Recommendations address harbour oversight, while the annexed bulletin discusses safe vessel separation and hand-held marker-buoy lines.
- 20252 Oct
Grounding and subsequent loss of the dive support vessel Jean Elaine
Investigation of Jean Elaine’s grounding and subsequent loss in Saint Peter’s Pool, Orkney, during scientific diving support. It examines inadequate passage planning, reliance on an unapproved tablet navigation application, ineffective coordination and unchecked certification. Poor hull condition likely contributed to failure after grounding; university and project procedures were subsequently revised.
- 202525 Sep
Collision between the tender to Isabell Princess of the Sea and the RIB Vega, resulting in one fatality
Investigation of a fatal collision between a yacht tender and the drifting RIB Vega in Göcek harbour. It examines unsafe speed, night visibility, unused chart-plotter information, possible alcohol impairment and unclear command authority. The passenger died from collision injuries and drowning; subsequent actions addressed tender operations, authority and navigation-light compliance.
- 202517 Sep
UK HSE: oil company fined after serious failure of elevator
An IMCA safety flash describes three workers encountering water while descending in a lift on the FPF-1 platform for inspection work. They stopped the lift and returned safely without injury. Hardware failures, incorrect operating procedures and absent water alarms were identified; enforcement included a £300,000 fine and an improvement notice.
- 202517 Sep
Uncoordinated Emergency Shutdown due to pipe failure
A tanker cargo discharge stopped when a duty AB activated emergency shutdown after observing a minor leak, without coordinating with the cargo control room. Copper tubing had failed through vibration fatigue. The flash describes revised shutdown procedures, coordination training and periodic vibration risk assessments, with tubing dampers or supports under consideration.
- 20254 Sep
BSEE: Electromagnetic lifting device dropped steel plate
This safety flash summarises a BSEE incident in which a steel plate detached from a worn magnetic lifting device, fell approximately 1.2 m and injured two workers’ feet. It discusses inadequate task hazard analysis and stop-work culture, alongside recommendations for inspections, load testing, power stability and electromagnetic lifter operating procedures.
- 20254 Sep
Hand crushed during coiled tubing reel handling
A worker suffered severe hand injuries and partial amputations of three fingers while aligning a coiled tubing reel into a cradle. A securing frame shifted and trapped the hand. The flash identifies entrapment-prone design, inadequate instructions and incomplete risk assessment, recommending hands-free guiding, equipment familiarisation and improved toolbox talks.
- 20254 Sep
MSF: Grease gun hand injury
A crew member suffered a grease injection injury through a glove while disconnecting a battery-powered grease gun hose during tensioner maintenance. The flash reports a malfunctioning pressure release valve and possible handling and training shortcomings. Lessons emphasise manufacturer instructions, pre-use hose and nipple inspections, suitable gloves and consideration of safer tools.
- 2025Sep
Several errors lead to a hydrogen leak & fire — Process Safety Beacon, September 2025
This bulletin examines a hydrogen filling incident in Santa Clara in which a trainee inadvertently restarted filling while piping was dismantled for repair. Escaping hydrogen ignited, producing a deflagration and jet fire. It emphasises isolation procedures, authorised repairs, understandable controls and clear instructions for newer employees.
- 202521 Aug
Serious injury to a passenger on the sea safari rigid inflatable boat Lundy Explorer
Investigates a passenger’s permanent spinal injury during wave-induced slamming aboard Lundy Explorer at Ilfracombe. Examines forward jockey seating, passenger bracing, safety briefings, sea-condition decisions and regulatory gaps. Records restrictions on forward-seat use and recommends improved operating procedures and risk assessments within a safety management system.
- 202514 Aug
Shore-side crane boom collides with vessel mast
A dock crane boom struck a vessel mast during shipyard lifting, dislodging wind and GPS sensors onto the deck. The flash describes poor visibility, ineffective banksman positioning and crane movement without signals. Discussion actions emphasise banksman roles, clear communication and providing dockyard management with vessel layout and dimensions before operations.
- 20251 Aug
BSEE Safety Alert - 504 - Malfunction of Rental Generator's Engine Air Shutoff System
A rental generator fire on an offshore platform followed a closed right-bank air flap, allowing unburnt diesel and excess oil to accumulate and ignite with heat from the operating left bank. The alert recommends considering improved maintenance checks, alarm verification, training and procurement assurance, including independent testing of each emergency air flap.
- 2025Aug
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
Dive chamber procedures and operations
A chamber operator began venting an outer lock while a diver remained inside following surface decompression diving. Recompression and treatment for omitted decompression followed; the diver remained asymptomatic. The flash examines assumptions, poor visibility and missing transfer checks, stressing diver signals and operator and supervisor verification before venting.
- 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.
- 202518 Jul
Capsize and sinking of fishing vessel Njord with loss of 1 life
Investigation of Njord’s capsize and sinking while processing a large catch, with one crew member drowning. Analysis examines catch loading, downflooding through an open drain valve, vessel modifications and stability-book assumptions. Indicative digital stability modelling supports the findings, alongside examination of flotation protection, liferaft deployment, emergency communications and rescue.
- 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.
- 20253 Jul
LTI: Hand injury during capstan maintenance
A crew member suffered a serious hand injury while greasing a vessel capstan when rotation trapped his hand between an underside wire clamp and the deck. The flash examines difficult access and grease-gun design, describing grease-point extensions, clamp removal, revised maintenance procedures and wider inspections for line-of-fire hazards.
- 20253 Jul
UK HSE: load falls from lorry and kills cyclist
A cyclist was killed when a heat exchanger weighing over 2.5 tons fell from a lorry after its load shifted on a bend and a securing strap snapped. HSE identified inadequate securing, poor-condition ratchet straps and missing load-security training and securing instructions. Lessons emphasise suitable securing equipment and trained personnel.
- 2025Jul
CHIRP Superyacht FEEDBACK 10
Six superyacht reports examine dismissed safety concerns, inconsistent fall protection, unsafe pilot boarding, crew abandonment, a mooring-line injury and chemical burns. Commentary addresses leadership, reporting protection, procedural compliance and task risk assessment. An appended flag-state flyer reinforces safe working at height, equipment training and intervention in unsafe work.
- 202520 Jun
BSEE Safety Alert 503 - Personnel Burned by Fire due to Improper Venting of Gas Starters on Engines
BSEE describes two flash fires during attempts to start gas engines driving pipeline pumps. Improperly secured or absent starter exhaust piping allowed gas to accumulate before backfires ignited it, burning workers. Recommendations address safe exhaust routing, component checks, training, startup and maintenance procedures, gas detectors and consideration of temporary fire watches.
- 202518 Jun
BSEE: Umbilical termination failure leads to dropped ROV
An ROV dropped to the seafloor during recovery when its umbilical parted at the cursor rail transition. Faulty resin casing and improperly arranged armoured strands compromised the attachment despite a previous successful pull test. BSEE recommends termination inspection procedures, re-termination training and pre-job connection checks. No personnel harm or seabed asset damage occurred.
- 202518 Jun
Dropped object hazard: access hatch to the communication dome
A scheduled mast inspection identified a detached communication-dome hatch. Its primary securing mechanism had failed, while an undersized secondary lanyard used adhesive pads that detached. The flash recommends mechanically fixed, appropriately rated secondary retention, anti-loosening measures, planned maintenance and procedural double checks after work.
- 202518 Jun
Dropped pallet during forklift operation
A safety flash describes a 500kg pallet load falling from a flatbed truck and narrowly missing its driver during forklift unloading. It identifies load positioning, a high centre of gravity, fork positioning and personnel positioning issues. Lessons include revised forklift procedures and ensuring suppliers pack and deliver loads safely.
- 202516 Jun
Heat Stress Hazard Alert
This alert explains heat-related illness symptoms and occupational and personal risk factors for oil and gas extraction workers. It outlines employer, supervisor and worker responsibilities, covering acclimatisation, work–rest schedules, hydration, cooling areas, buddy systems, protective clothing, medical screening and training to recognise and respond to heat illness.
- 20259 Jun
BSEE Safety Alert 501-BSEE Identifies Bypassed Safety Device Deficiencies
BSEE inspections of five production platforms identified poorly documented safety-device bypasses, non-operational data historians and overly broad maintenance bypasses. Findings included pressure protection disabled during startup and unreverted ladder-logic changes. Recommendations address bypass logs, electronic records, interface visibility, construction changes and verification of procedural compliance.
- 20254 Jun
LTI: Back injury in Confined Space (Tank Entry)
A worker injured their lower back after losing hand grip while exiting a confined compartment feet-first through a lightening hole during planned maintenance. The flash examines access ergonomics and gaps in risk assessment, describing additional grab handles, possible platforms under investigation and a review of confined-space entry procedures.
- 20253 Jun
TS USA Molten Salt Eruption
Investigates the fatal molten-salt eruption at TS USA’s Chattanooga facility on 30 May 2024. Retained water in a plugged roller generated pressure before entering the oxidising bath and producing a steam explosion. Examines drainage hazards, reprocessing procedures, training, protective barriers and failures to share learning from earlier incidents.
- 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.
- 202516 May
Electrical isolation: Failing to “prove dead” at the point of work
This safety flash examines failures to verify that electrical equipment is dead at the actual work location rather than only at a remote isolation point. Two examples describe personnel accessing live terminals after selecting the wrong thruster or ROV. It emphasises following proving-dead protocols at the point of work.
- 202516 May
MSF: Multiple LTIs - Vessel gangway fell from quay causing injuries
Five workers were injured when a container vessel’s gangway moved off the quay; one fell into the water. Tidal movement had positioned the gangway partly over a ladder void. The flash identifies absent supervision, slack hoist wires and faded markings, and presents suggestions on positioning, procedures, checks, signage and correct PPE use.
- 2025May
Risk from height adjustable display screen stands in schools and other education settings
This HSE safety notice addresses impact and crushing risks from motorised height-adjustable display mounts in education settings, including incidents injuring young children. It explains instability, unsuitable fixings and obstructed movement, and sets out responsibilities for users, installers, purchasers and suppliers, emphasising risk assessment, anti-collision protection and restricted access to controls.
- 202529 Apr
BSEE: Nitrogen cylinder rupture causing worker injuries and equipment damage
A nitrogen cylinder ruptured at its base during preparations to pre-charge accumulator cylinders, dispersing cylinders and debris and causing minor shrapnel injuries to three rig personnel. BSEE attributed the failure to corrosive wall loss aggravated by environmental and structural conditions. Recommendations address recertification, filling pressure, training, inspection and corrosion-preventive maintenance.
- 202529 Apr
Hydrogen Sulphide (H2S) detected onboard vessel
A vessel-wide odour prompted crew to investigate with gas detectors but without respiratory protection. Hydrogen sulphide reached a measured 170 ppm in the Grease Trap room, entering through a dry drain trap. The flash examines sewage-system maintenance, incomplete procedures and risk assessment, and subsequent revisions to tank-flushing, drain-trap and emergency arrangements.
- 202529 Apr
Person fractured foot during elevator inspection
A worker fractured their foot during a vessel elevator inspection when released trunk doors disengaged the interlock, allowing upward cage movement before local service mode was activated. The flash identifies an unfollowed manufacturer procedure, absent toolbox talk and inadequate communication, and calls for applicable work controls and risk assessment.
- 202516 Apr
BSEE: Crane safety awareness during offshore helideck operations
An offshore helicopter landing nearly ended in collision when a crane operator raised the boom as the aircraft was 10 feet from touchdown. The pilots performed a successful go-around. Drawing on BSEE findings, the flash highlights procedural enforcement, communication and coordination, with recommendations also applicable to vessel approaches and simultaneous operations.
- 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.
- 202510 Apr
Swamping of small commercial vessel Calypso 2 with loss of 2 lives
Investigation of Calypso 2’s swamping in a coastal cove in Anguilla, resulting in two drowning fatalities. The report examines exposure to ground seas, excursion risk assessment, passage planning, flotation-device use and regulatory oversight. It also analyses distress alerting, casualty recovery and medical provision, recommending improvements to vessel management and rescue arrangements.
- 20254 Apr
BSEE Safety Alert 499 - Failed Umbilical Termination Results in Dropped Remotely Operated Vehicle (ROV)
An ROV dropped to the seafloor during recovery when its umbilical termination failed at a cursor transition point. Faulty resin and improperly positioned armoured strands were identified despite a previous successful pull test. BSEE recommends termination inspection procedures, training and pre-job connection checks. No personnel harm or seabed asset damage occurred.
- 20253 Apr
BSEE Safety Alert 498 - Explosion and Fire Incident
A liftboat explosion during separator draining injured two workers with burns. Gas accumulated on deck and a generator surge triggered ignition. The alert examines tank sealing, unsuitable gas detectors, failed air-intake shutoff controls and delayed medical evacuation, recommending that operators consider improved procedures, inspections, testing and emergency arrangements.
- 2025Apr
Knowing ‘why’ makes tasks safer — Process Safety Beacon, April 2025
This bulletin compares valve actuator removal incidents in La Porte in 2021 and Baton Rouge in 2016. It highlights missing procedures and training, and stresses understanding why critical tasks follow specified steps. Recommendations include illustrated instructions, signed checklists, demonstrated competence and checking procedures against field conditions.
- 202519 Mar
LTI: rope under tension moved and hit person’s hand
A crew member sustained serious finger injuries when a tensioned winch rope jumped a slipway side during equipment recovery to a vessel. The flash identifies sea-induced movement, an unrecognised hazard area and unsuitable vessel design, and describes revised work instructions, a recovery no-go area and task redesign.
- 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.
- 20256 Mar
BSEE Safety Alert - 496 - Misidentification of Corrosion Hazard Results in High Potential Event
A worker installing a pump at a Gulf production facility supported himself on nearby piping when corroded grating gave way beneath scaffold boards. Previously installed barricades had been removed. The alert recommends facility walkthroughs, secure restriction of unsafe areas and review of safe work practices governing barricades.
- 20256 Mar
Divers helmet struck and damaged subsea by crane hook
A crane hook slipped from a pipe handling frame during subsea spool tie-in work in poor visibility, striking and irreparably damaging a diver’s reclaim helmet without injury. The flash identifies insufficient pennant length and discusses safe separation, position monitoring, reinforced communication, rigging inspections and revised task hazard analysis.
- 20256 Mar
MAIB: Very serious leg injury during crane operations
An IMCA flash summarises a MAIB investigation into a second officer’s leg injury aboard Kommandor Orca. His leg was trapped in a deck crane’s rack-and-pinion traversing mechanism, requiring below-knee amputation. Findings highlight unsafe local operation, omitted permit hazards, absent onboard operating procedures and flawed training.
- 2025Mar
Risk of collision with offshore installations from attendant vessels
HSE safety notice examines five vessel collisions involving offshore installations and wind turbines. Cases highlight distracted watchkeeping, lost situational awareness, environmental conditions and poor bridge communication. Recommended reviews cover watchkeeping instructions, bridge resource management, navigational alarms and vessel monitoring, with consideration of sailing audits to identify operational bad practice.
- 20256 Feb
Confined space entry hot work fatality
A welder died after entering a pipe to check welding in a shipyard. The flash identifies shortcomings in entry restrictions, supervision, communication, procedures and assessment of argon-related risks. Actions included barriers and signage at specified pipe openings, revised restricted-space procedures, and additional inert-gas input to risk assessments and work permits.
- 20256 Feb
MAIB: Vessel cook injured by spillage of burning cooking oil
A cook aboard an offshore support vessel suffered severe burns when wet chemical suppression displaced burning oil from a shallow-sided gyro pan. A faulty thermostat and unsuitable use for deep-frying featured in the incident. Lessons address hazardous work-arounds, regular maintenance, testing overheated appliances and following manufacturers’ guidance.