Topic
Loss of Containment
Unintended escape of process fluids or substances from their intended containment.
Newest 100 Documents
All 397 in search- 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.
- 202614 May
Shifting cargo and deck spill during heavy weather
During heavy-weather transit, a brine storage tank shifted approximately 0.5 m, struck a crash rail and damaged its manifold valve, spilling brine onto the deck. The flash identifies slackening lashing chains and inadequate securing, and recommends redundant lashings, impact protection for vulnerable fittings and review of weather risk assessments.
- 2026Apr
Emergency response systems save lives! — Process Safety Beacon, April 2026
This issue examines an ammonia release at a Virginia food processing facility where evacuees encountered the outdoor cloud and four employees were hospitalised. It highlights shortcomings in alarms, emergency shutdown use and release-specific planning, emphasising trained responders, regular drills, safe relief discharge locations and wind-dependent evacuation routes.
- 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.
- 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.
- 2026Feb
Well Workover
This regulatory inspection guide presents compliance questions for oil and gas well-workover operations. It covers prior approval, well-control fluid replenishment and measurement, crown-block safety checks, mud-pit level warnings, tubing and wellhead requirements, wireline leakage prevention, and pressure testing of newly installed lubricators against expected shut-in surface pressure.
- 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.
- 202525 Sep
Cuisine Solutions Ammonia Release
CSB investigates an ammonia refrigeration release at Cuisine Solutions in Sterling, Virginia, which injured workers during evacuation. Relief-valve testing and dispersion modelling examine overpressure, liquid aerosol and unsafe discharge. The initiating upset remains undetermined. Recommendations address relief-system assessment, process-data retention, ammonia alarms and emergency preparedness.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 202513 Mar
Marathon Martinez Renewable Fuels Fire
Investigation of a renewable diesel startup fire at Martinez, California, following heater tube rupture. Low process flow and afterburning caused overheating, releasing diesel and hydrogen and seriously injuring an operator. The report examines valve alignment, instrumented safeguards, combustion monitoring, alarm responses, human factors and corporate oversight, with recommendations and comparisons to earlier incidents.
- 2025Feb
Communication is the key to safer operations — Process Safety Beacon, February 2025
A bulletin examines unclear torque instructions during pipefitting work that led to a hydrogen chloride release and workers falling while escaping. It contrasts equipment manuals with design drawings and promotes clear written instructions, field demonstrations of critical tasks, worksite permit reviews and radio message repeat-back.
- 2024Sep
F-Gas Guidance September 2024
Revised guidance for offshore oil and gas operators and service companies explains fluorinated greenhouse gas obligations. It covers technician qualifications, equipment labelling, carbon dioxide equivalence calculations, use restrictions, leak checks and detection systems, recovery and disposal during decommissioning, record retention, emissions reporting, inspection and civil penalties.
- 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.
- 20249 Jan
Leak in hot water system for saturation divers
A saturation-diving hot-water unit leaked through locally corroded pipework inaccessible for visual inspection. Diving was suspended because the remaining unit lacked backup. Repairs involved welding a sleeve over the leak and inspecting the other unit. The flash suggests considering wall-thickness measurements of old pipes.
- 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.
- 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.
- 202330 Nov
Yenkin-Majestic Resin Plant Vapor Cloud Explosion and Fire
Investigation of a fatal resin-plant explosion and fire following solvent vaporisation and release through an altered reactor manway. The report examines pressure-containment design, inadequate alteration assurance, agitator-dependent safeguards, alarm deficiencies and evacuation preparedness. Recommendations address low-pressure vessel guidance, safer process design and flame-resistant clothing.
- 202313 Nov
Failure of AHC cylinder causing oil leak to deck
An offshore vessel’s heave-compensated crane suffered a hydraulic cylinder failure during jumper installation. Worn seals allowed oil to accumulate behind the piston, leading to end-cover bolt failure. Approximately 150 litres remained contained aboard. Proposed actions address pressure alarms, seal inspections, return-filter checks and planned cylinder overhaul.
- 20239 Nov
Safety Alert 472 - Tote Tank Drain Nozzles Pose Leak Hazard
Two Gulf of Mexico lifting incidents illustrate how protruding tote-tank drain nozzles can strike nearby objects, causing diesel spillage or a cracked weld and minor leak. BSEE recommends considering nozzle positioning, clear transport paths, protective guards, conditional drain securing or nozzle removal, conspicuous marking and spill-response provisions.
- 20232 Nov
H2S released during rig reactivation activities
During quayside rig reactivation, hydrogen sulphide escaped from a machinery-space bilge water tank after its top hatch was removed, threatening nearby personnel. The alert describes acute inhalation dangers, including immediate collapse at concentrations above 1,000 ppm, alongside steel corrosion and flammable or explosive concentration limits.
- 202329 Aug
BSEE: Improper use and application of high-pressure hoses
An offshore inspection identified a hydraulic hose unsuitable for nitrogen during pressure safety valve testing. Injection of nitrogen at 2500 psi caused blistering and leakage. The flash summarises BSEE recommendations for operators and contractors to consider hose selection, fluid compatibility, inspection and replacement intervals, damaged-hose disposal, work permits and hazard communication.
- 202329 Jun
Improper Use High Pressure Hoses Leads to Injuries
An offshore inspection identified a hydraulic hose unsuitable for nitrogen service that blistered and leaked when pressurised to 2500 psi. The alert recommends considering hose selection, fluid compatibility, temperature, inspection and replacement intervals, alongside work permits, job safety analyses and communication of pressurised-hose hazards.
- 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.
- 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.
- 202327 Mar
Leak of oil-based mud
A vessel preparing to transfer oil-based mud to shore spilled about 20–25 litres through tank ventilation during hose pressure testing. A deteriorated valve seal prevented full closure. The flash describes deck containment, toolbox communication, valve replacement, monthly manifold-valve cleaning and clearing residual chemicals or mud from transfer lines.
- 202327 Feb
Compressor fire
A rented diesel-driven screw compressor caught fire aboard a diving support vessel. An electrical short circuit damaged cable insulation; radiant heat compromised an oil scavenger line, releasing oil that ignited. No injuries occurred. The flash discusses maintenance testing gaps, pre-mobilisation checks, equipment assessments, fire suppression and deck positioning.
- 2023Jan
Hydrogen Sulfide Release
This fatality alert describes hydrogen sulphide poisoning that killed a worker responding to a pump alarm and, later, his spouse at an oil production facility. It examines defective gas detection, missing detector-use policies, inadequate isolation arrangements and visitor access, alongside recommendations for lockout/tagout, ventilation assessment and detection-system assurance.
- 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.
- 202210 Nov
BSEE: Hazards associated with cranes on idle facilities
This flash summarises BSEE observations of deteriorated cranes on idle Gulf of Mexico facilities. Corroded cables, degraded slings and leaking reservoirs present dropped-object and pollution hazards. Recommendations address removing or temporarily securing blocks and balls, inspecting cranes before return to service, storing or discarding slings, and clearing reservoirs and hoses.
- 20221 Nov
Hydraulic Oil Leak to Sea from Downline Fitting
During decommissioning with a diamond wire saw, 100 litres of hydraulic oil escaped to sea through a slack BSP downline fitting. Tightness checks had been omitted because the checklist prompted only visual inspection. Actions included physical tightness checks, checklist revision, additional fitting supports and removal of the hydraulic hose bight following feasibility review.
- 2022Oct
Communication – the heart of safe operations — Process Safety Beacon, October 2022
A solvent-transfer incident illustrates how unclear maintenance status and informal lockout arrangements can undermine safe restart. An operator was sprayed with solvent from an improperly tightened flange but was not injured. The bulletin emphasises work permits, communication between groups, participation in hazard reviews and following restart plans.
- 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.
- 202122 Sep
Failure of in-service saturation bailout bottle
A saturation diver’s bailout bottle lost pressure through wall defects associated with internal corrosion. Similar bottles were quarantined and operations suspended. Moisture was identified as the primary factor, while third-party testing or unsuitable storage was suspected. The flash calls for improved servicing specifications, procedural assurance, receipt inspection, drying and sealing.
- 202124 May
Measurement While Drilling (MWD) Lithium Thionyl Chloride Cell Battery Explosion
An explosion occurred during the second attempt to lower a measurement while drilling tool into a drill collar. A discharged vent plug shattered the driller’s cabin glass, sending glass and chemicals inside. The driller was struck in the face and neck; other rig-floor employees sustained minor injuries from concussion and gas release.
- 202121 May
Aghorn Operating Inc. Waterflood Station Hydrogen Sulfide Release
This investigation summary examines a fatal hydrogen sulphide release at an Odessa waterflood station that killed an employee and his spouse. It identifies a broken pump plunger, while leaving failure timing unresolved, and examines detector nonuse, missing lockout procedures, inadequate ventilation, detection and alarm failures, and deficient site security.
- 202130 Mar
Engineer suffered burn injuries in engine room incident
An engineer aboard Mineral Temse sustained severe burns after opening a sludge discharge inspection plug shortly after switching off a fuel oil separator. The flash summarises findings concerning unrecognised heating and pressurisation during complete blockage, unaccompanied inspection and inadequate skin protection, alongside onboard first aid and subsequent hospital treatment.
- 2021Feb
Failure of a road tanker pressure/vacuum relief valve
HSE safety alert describes a modified road-tanker relief valve that stuck open, releasing nitric acid vapour without injuries or property damage. A welded nut obstructed the valve stem. It calls for visual checks for unauthorised modifications, manufacturer-guided servicing and verification of both pressure and vacuum protection functions.
- 202010 Dec
Entry to enclosed space on fishing vessel Sunbeam with loss of 1 life
Investigates a fatal tank entry aboard Sunbeam in Fraserburgh. Leaking refrigerant from corroded evaporator tubes displaced air in a refrigerated salt water tank. The report examines inadequate repairs, non-gastight isolation valves, normalised unsafe entry, absent atmospheric precautions, rescue arrangements and gaps in machinery survey oversight.
- 202023 Oct
MSF: Grub screws and perished valves – trouble with methanol transfer
This flash describes unrecognised methanol discharge to sea during vessel cargo transfers. An incorrectly retained spool piece and passing valves allowed flow through the flushing line; a grub screw restricted one valve’s closure. Recommendations address recorded cargo receipt confirmation, transfer-system configuration checks and updating planned maintenance.
- 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.
- 202025 Aug
High potential near miss: Nitrogen hose failure during transfer of gas
A nitrogen transfer hose detached from its ferrule, releasing approximately 165,000 litres into a pipelay HPU room and reducing oxygen to approximately 17.4%. The degraded hose was absent from the hose register and maintenance regime. The flash recommends rated whip restraints and hose inspections, and records restricted-access signage and low-oxygen alarms.
- 202014 Aug
Near miss/positive: Internal O-ring seal found damaged on fuel system
A fuel gas cylinder connected to a forklift aboard a vessel alongside leaked at the cylinder–hose connection. Inspection revealed damaged O-ring seals in both the original and replacement cylinders. The flash highlights successful pre-fitting checks, supplier corrective action and the importance of examining exchanged equipment before use.
- 202012 Jun
MSF: Water-based mud spill on deck
A mud-transfer hose separated from a vessel manifold at an offshore installation, spilling approximately 2,500 litres onto deck. Incompatible threads allowed corrosion to weaken the connection. The crew contained and recovered the mud without environmental loss. Actions address thread compatibility, planned maintenance and visual pre-use inspections.
- 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.
- 202022 May
Sewage spilled onto the quayside
A vessel-to-truck sewage transfer spilled 30–40 litres onto a contained concrete quayside, without discharge to sea. Preliminary causes included an incorrect hose connection, an unchallenged unsafe condition, missing radio communication and an incomplete checklist. Actions addressed compatible connections, whip checks, equipment condition, radios and transfer checklists.
- 202028 Feb
Safety Alert 379 - Broken Compressor Heat Exchanger Causes Fire
This alert describes a Gulf of Mexico platform fire after compressor heat-exchanger tubing detached and released gas that ignited at the engine exhaust, alongside a similar 2017 fire. It identifies inadequate inspection and maintenance, and recommends considering improved joint oversight and leak-detection methods, with exhaust routed outside classified areas.
- 202030 Jan
Explosion and fire on-board the chemical tanker Stolt Groenland
This safety flash summarises preliminary MAIB findings on explosions and fire aboard Stolt Groenland during ship-to-ship styrene monomer transfer at Ulsan. Investigators considered deck rupture from over-pressurisation followed by vapour ignition the probable explosion mechanism. The incident caused extensive vessel damage and injuries to crew and firefighters.
- 201916 Dec
Explosion and fire on chemical tanker Stolt Groenland
This interim investigation examines explosions and fire aboard Stolt Groenland at Ulsan. Initial findings link probable tank rupture and vapour ignition to over-pressurisation during styrene monomer polymerisation. It describes inhibitor dosing, cargo conditions, firefighting and evacuation, alongside a separate Stolt Focus incident and reminders on monitoring and carriage instructions.
- 201911 Dec
Safety Alert 374 - Air Compressor Flaws Lead to Engine Fire
An air-compressor fire on a Gulf of Mexico production platform followed regulator diaphragm rupture and hydraulic fluid release through PSV outlets. Fluid ignited on the hot exhaust manifold after shutdown. The alert recommends considering condition checks, additional pressure shutdown protection, controlled discharge arrangements and periodic diaphragm inspections.
- 201922 Oct
Update to SF 11/19: Fatality and multiple injuries – flash fire onboard pipe-lay barge
This flash updates a pipe-lay barge incident involving repair of stuck polypropylene field-joint coating equipment. Vapour and droplets escaped during piston extraction and ignited, injuring fourteen people; one later died. It describes medical evacuation and recommends temperature control through the integrated system and manufacturer consultation on permissible repairs.
- 201917 Sep
BBC news: Worker loses hand after he was injured with faulty hydraulic cutting gear
A firefighter suffered a hydraulic-fluid injection injury during a training exercise with cutting equipment. A punctured hose released a fine jet that penetrated his leather safety glove. Swelling and burning developed later that day; tissue damage ultimately led to amputation after 40 operations and a four-year battle.
- 201920 Aug
Catastrophic rupture of dead-leg pipe-work
This safety alert examines refinery pipework ruptures associated with highly localised internal corrosion in dead-legs. It explains how routine thickness checks missed deterioration and outlines inspection expectations, including risk assessment, wider wall-thickness testing and timely replacement. Operators should consider removing non-essential dead-legs and account for thermal gradients, liquid interfaces and condensation.
- 20197 Aug
Safety notice to act as a reminder of the phenomenon of condensate induced water hammer
HSE’s notice explains condensate-induced water hammer in existing steam systems following a steam release that injured three people. Early investigation findings suggest a pressure-boundary failure potentially caused by water hammer. It highlights drainage, steam-trap maintenance and statutory responsibilities, and recommends considering SAFed’s five-point action plan.
- 201925 Jun
DuPont La Porte Facility Toxic Chemical Release
Investigation of a fatal methyl mercaptan release at DuPont’s La Porte insecticide unit. Four workers died inside the manufacturing building. The report examines hydrate-blocked pipework, drain valves, inadequate safeguards, alarm communication and emergency response, alongside management of change, audit effectiveness, process safety culture and misleading reliance on occupational injury metrics.
- 201917 May
Fatality and multiple injuries: Flash fire incident onboard pipelay barge
A safety flash describes a vapour-cloud fire during attempts to remove a stuck piston from polypropylene coating equipment aboard a pipelay barge. Fourteen people were injured and one later died. With investigation ongoing, recommendations address polypropylene temperature limits, integrated heating controls and manufacturer consultation on permissible repairs.
- 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.
- 201925 Apr
Safety Alert 348 - Chemical Leak in Flying Lead Discovered by ROV
An ROV survey discovered a subsea paraffin-inhibitor leak from a hydraulic flying lead in the Gulf of Mexico. Outer-jacket damage compromised collapse resistance; loss of positive pressure resulted in collapse and tearing. BSEE recommends considering pressure-maintaining procedures, training, check valves, low-pressure alarms, inventory monitoring and regular ROV inspections.
- 20186 Dec
Safety Alert 344 - Chemical Containment Release
BSEE describes an emulsion-breaker release from a cracked polyethylene tote on an unmanned platform. Xylene incompatibility was considered a contributing cause, while weather exposure may also have contributed. Rainwater compromised secondary containment. Recommendations address compatible containers, correct labelling, chemical training and inspection for continued service.
- 20183 Dec
Glow sticks breaking open – chemical splash risk
Glow sticks from the same batch broke open during activation, releasing chemical dye. The flash discusses possible temperature-related brittleness and a manufacturing defect, without confirming either cause. Recommendations cover air-conditioned long-term storage, opening away from eyes, protective gloves, and checks on stock expiry or authenticity.
- 201819 Oct
Safety warning about working in enclosed spaces after the loss of 1 life on a fishing vessel
This bulletin presents initial findings from a fatal refrigerated salt water tank entry aboard Sunbeam at Fraserburgh. Testing found severe oxygen deficiency and Freon R22; refrigerant leakage through failed evaporator tubes was considered likely. It discusses hazardous rescue attempts and recommends tank-entry risk assessments, safe procedures and appropriate safety equipment.
- 201811 Sep
Unintentional release of carbon dioxide from fixed fire-extinguishing systems on ro-ro vessels Eddystone and Red Eagle
Investigation of unintended carbon dioxide discharges on Eddystone and Red Eagle examines leaking cylinder valves, system activation arrangements and maintenance deficiencies. Neither incident harmed anyone. The report analyses leakage alarms, pressure protection, valve testing and servicing, and recommends design reviews and improved survey assurance of safety devices.
- 20183 Aug
Near miss: onboard O₂ bottle leaked into diving bell
A diving bell near miss involved oxygen supply valves left partly open during pre-dive checks, emptying a bottle into the bell. Distraction, delayed topside readings and distrust of an unreliable analyser were identified. The run was aborted; subsequent measures included atmosphere flushing, additional valve checks, analysers and sourcing buffer tanks.
- 20183 Aug
Safety Alert 339 - Running of Gas Sensing Line in Cable Tray Leads to Fire
An electrical wiring defect on a Gulf of Mexico production platform generated an arc that damaged a gas pressure sensing line sharing the cable tray. Leaking fluid ignited without causing injuries. BSEE recommends operators consider inspecting trays, separating non-electrical piping, reviewing installation procedures and ensuring installation competence.
- 2018Aug
What if your agitator fails? — Process Safety Beacon, August 2018
This bulletin examines a German batch-reactor incident in which restarting agitation mixed accumulated reactants, rapidly raising temperature and releasing contents through a relief valve. It explains mixing and heat-transfer hazards, including in non-reacting vessels, and recommends obtaining technical assistance and reviewing operating history before restarting an agitator after loss of agitation.
- 20186 Jul
Personnel certification in non-destructive testing (PCN) scheme fraud
HSE alerts duty holders to fraudulent PCN certification involving NDT International PTE Ltd and uncertain technician proficiency. It explains potential implications for equipment integrity, including imported equipment and in-service examinations, reviews relevant regulations, and advises assurance in consultation with competent persons, with options for checking technician details and certificate validity.
- 201824 Apr
Dropped object – intermediate bulk container (IBC)
A vessel crane dropped an IBC containing monoethylene glycol approximately 3.5 metres onto the deck after liquid movement shifted its centre of gravity and the rigging could not support it. The flash discusses unsuitable rigging selection, inadequate risk assessment, load movement in lift planning and replacement of pallet-type arrangements with certified lifting frames.
- 201819 Apr
Small Bore Tubing Failure on BOP Control System
This alert describes a hydraulic-fluid release during maintenance when a BOP stack control system was started. Small-bore tubing separated from the system’s 3,000 PSI manifold. An estimated 196 litres (51 gallons) of fluid escaped into a bunded area.
- 201822 Mar
Technical Service Bulletin from Broco/Rankin – BR22 Plus Exothermic Cutting Torch
This safety flash highlights a Broco/Rankin bulletin concerning an external oxygen leak from a BR22 PLUS exothermic cutting torch. Investigation identified machining debris interfering with the valve’s oxygen seal. The supplied pages identify the leak location and describe torch preparation using an 18-inch cutting rod.
- 20182 Mar
Loss of Containment (LoC) - Version 2 March 2018
Inspection guidance for assessing offshore oil and gas duty holders’ containment safeguards. It covers design, commissioning, operating limits, instrumented protection, relief, isolation, reinstatement and change management. Specialist sections address process hazards, FPSOs, tubing and hoses, alongside investigation, performance indicators, assurance and leadership.
- 20183 Jan
MGPI Processing, Inc. Toxic Chemical Release
This case study investigates an incorrect sulfuric acid delivery connection to a sodium hypochlorite tank at MGPI in Atchison, Kansas, producing a chlorine-containing cloud. It examines unloading equipment design, pipe identification, procedure compliance, training, remote shutdown, control-room ventilation and escape respirator access, alongside community emergency planning and subsequent preventive changes.
- 20177 Dec
Environmental Alert 003/2017
An environmental alert describes a chemical release to sea during storage-tank commissioning. A design–construction discrepancy left the overflow lower than expected; filling above it and subsequent syphoning caused the release. Duty holders should verify overflow positions and may prudently consider water first fills with robust monitoring where possible.
- 201725 Oct
Two near miss incidents with a risk of scalding
Two vessel near misses involved scalding water: boiler blowing sent water from the funnel onto the boat deck, while engine shield installation dislodged a cooling water pipe. Lessons address failure to embed previously recognised hazards into routines, reassessment as work becomes more complex, system isolation and communication of maintenance tasks.
- 201720 Oct
US Coast Guard Safety Alert 07/17 – CO₂ hazards
This safety flash describes two vessel incidents involving carbon dioxide fire-extinguishing systems. Incorrect heat-actuator testing left a chief mate unconscious, while servicing primed another system for release and personnel accounting missed an inspector. Recommendations emphasise evaluated competence, understanding test steps, pre-test communication and reliable personnel accountability.
- 201718 Oct
Safety Alert 325 - Bolt Failures
BSEE describes subsea connector bolt failures during a BOP high-pressure test, with leakage but no loss of well control or injury. Material suitability and heat treatment remained suspected causes under investigation. Recommendations address replacement of affected-lot bolts, material compliance, installation and maintenance procedures, and timely failure reporting.
- 20171 Oct
Well Examination Scheme - Issue 4
Inspection guidance for assessing well operators’ examination schemes across the well life cycle. It addresses documentary assurance, examiner independence and competence, management of changes, barrier verification and interfaces with installation verification. Interview material and success criteria support consistent recording of findings, compliance scoring and regulatory intervention planning.
- 201721 Sep
Failure of pipework in fuel tanks
Seawater leaking from pipework running through a vessel’s fuel tank raised the tank level. Subsequent fuel transfer was followed by a separator trip, and checks found water in the system. The flash identifies pipework failure and highlights visual inspection and ultrasonic baseline thickness measurements.
- 201711 Aug
Incorrect pressure gauge on high pressure supply line
A new, incorrectly selected pressure gauge leaked steam when its safety seal failed during recommissioning. A lookalike percentage gauge had been retained locally after an ordering error and installed instead of a pressure gauge. Recommendations address stores organisation, returning unused equipment, functional checks before installation and rationalising redundant gauges.
- 201710 Aug
Carbon monoxide poisoning on motor cruiser Vasquez with loss of 1 life
Investigation into fatal carbon monoxide poisoning aboard Vasquez while moored at Cardiff Yacht Club. Leaking wet-exhaust bellows allowed fumes into the cockpit and cabin; two rescuers also suffered poisoning. Reconstruction measured accumulating gas. The report discusses modified exhaust components, engine servicing, ventilation and carbon monoxide alarms.
- 201727 Jun
Chemical spill leads to costly deck replacement
A safety flash describes damage beneath a vessel’s cargo deck after a caustic soda spill. Washing with water left diluted chemical trapped beneath wooden planking, where a reaction damaged aluminium supports. It highlights corrosion, potential personnel health risks and conditional generation of flammable hydrogen when caustic soda encounters aluminium.
- 20179 Jun
Huge leak discovered in fresh water system
Daily tank soundings revealed a vessel had lost 35 tonnes of fresh water over 24 hours. Checks traced continuous overboard discharge to bain-marie valves left open, without visible overflow. Inadequate supervision was considered the root cause. Valve-location and position signage was displayed, and valve operation explained to mess crew.
- 201712 May
LTI: Contact with refrigerant gas causing hand injury
An engineer sustained severe freezing burns to both hands after inadvertently opening a valve while checking a vessel’s operating air-conditioning system. The flash examines ratchet direction, exposure to released refrigerant, inadequate task assessment and unsuitable gloves, and sets out actions concerning training, permits, discharge arrangements and prompt injury reporting.
- 201711 May
Freedom Industries Chemical Release
Investigates the Freedom Industries chemical spill in Charleston, West Virginia, where internal tank-floor pitting corrosion released a mixture into the Elk River and public water supply. Examines deteriorated secondary containment, inspection deficiencies, treatment limitations, water testing, emergency communication and regulatory gaps, with recommendations for source-water protection and contamination response.
- 20173 May
Near-miss: Gas release from subsea pipeline
A gas release occurred during subsea spool connection while divers were in the bell for shift changeover. The vessel moved clear and an ROV released the crane hook safely. Findings highlight missing refinery communication about valve opening; recommendations address permit understanding, inter-site communication, H2S preparedness, drills and equipment testing.
- 2017May
Corroded Tanks — Process Safety Beacon, May 2017
This bulletin describes two fatal refinery incidents involving corroded tanks: a hot-work ignition of flammable vapours and an operator falling through a weakened hot-oil tank roof during manual measurement. It highlights uncorrected defects, reporting and escalation of corrosion concerns, and avoiding access onto unsuitable or badly corroded equipment.
- 20164 Dec
Failure to report hydraulic leak subsea
During diver monitoring of a subsea manifold valve, a hydraulic release went unrecorded and unreported. The client discovered it some four months later through video review. The flash identifies unfamiliarity with reporting procedures and unclear processes for additional works, emphasising pollution notification requirements and their inclusion in dive plans.
- 201624 Oct
Spilt acid during lifting operations
During cargo delivery to a jack-up rig, vessel motion allowed a lifted load to strike an acid drum, causing a contained deck spill without injury. The flash highlights communication, weather-sensitive risk assessment, deferring operations in unfavourable weather and consideration of cage-protected drums.
- 20161 Sep
Crewman badly scalded during tank cleaning
A crewman suffered first- and second-degree burns during hot-water cleaning of lube oil tanks when a pressurised hose released hot seawater. The investigation identified a defective or improperly locked camlock securing mechanism as the most likely cause. The flash records protective equipment, prior risk assessment and safety-shower cooling.
- 20162 Aug
Tesoro Martinez Sulfuric Acid Spill
CSB case study examines two sulfuric acid releases at the Martinez refinery in February and March 2014, injuring four workers. It analyses sampling-system integrity, protective equipment, pipe preparation and isolation, alongside process safety culture and missed incident learning. Comparisons with other refineries inform discussion of safer sampling arrangements.
- 20164 Jul
Accidental discharge of bilge water in dry dock
This safety flash describes bilge water draining into a graving dock after personnel opened the wrong tank bottom plug. Findings identify inadequate communication and supervision. Preventative actions address docking-plan markings, confirmed plug identification, Chief Officer supervision, recorded risk assessment and toolbox talks. Absorbent sheets removed oil traces; no basin pollution was reported.