Topic
Pressure Systems
Hazards and integrity of systems containing pressurised fluids or gases.
Newest 100 Documents
All 584 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.
- 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.
- 202628 Apr
BSEE Safety Alert 516 - BSEE Identifies Compressed Gas Cylinder Hazards During Risk-Based Inspections
Following reported cylinder-failure explosions, BSEE inspected 20 Gulf assets and identified gaps in cylinder marking knowledge, inspection programmes, maintenance and contractor assurance. The alert presents findings on storage, corrosion and recharging, and asks operators and contractors, where appropriate, to consider improved labelling, documented inspections, overpressure protection and training.
- 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.
- 202617 Mar
Unsafe handling of gas cylinders
A Chief Mate identified unsecured compressed gas cylinders on the quayside before planned gas cutting and welding during vessel maintenance. The flash discusses contractor awareness, perceived time pressure and unavailable securing arrangements, highlighting approved racks, restraint, contractor coordination and crew confidence to stop unsafe work.
- 2026Mar
Production PINCs
Numbered regulatory inspection questions address production safety systems, well barriers and casing-pressure diagnostics. Checks cover shutdown valve operation, gas and fire detection calibration, firewater pumps, pressure relief and protective devices on process equipment. Conditional approval requirements and specified testing intervals support inspection of production facilities and subsea components.
- 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.
- 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.
- 20253 Dec
BSEE Safety Alert - 509 - Miscommunication and Trapped Pressure Causes Injury
An offshore contractor was injured when trapped gas pressure ejected a bonnet flange during control-valve maintenance. The alert identifies unverified isolation, missing authorisation, miscommunication, unsafe scaffold use and omitted retaining nuts. Recommendations address zero-energy verification, collaborative job safety analysis, operational support, fall protection and adherence to manufacturer procedures.
- 20257 Nov
ATSB: Undocumented modification contributed to steam burns
An oil tanker maintenance team suffered burns when hot condensate escaped during steam valve bonnet removal. The ATSB found insufficient cooling time and an undocumented drain-line modification that likely weakened isolation. The flash highlights formal management of change, recording and assessing changes, adequate cooling and visual confirmation of isolation.
- 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.
- 202511 Sep
BSEE Safety Alert 507 - Improper Use of Equipment and Tools Increases Risk of Fires and Explosions Offshore
BSEE identifies recurring offshore tool misuse involving live electrical circuits, explosive atmospheres and high-pressure or high-temperature systems. Cases include unsuitable hand tools and a plumber’s plug used during welding. Recommendations address competence evaluation, tool ratings and tracking, maintenance, pre-work audits, qualified inspections and authority to halt unsafe work.
- 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.
- 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.
- 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.
- 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.
- 202519 Mar
Acetylene gas explosion
Two engineers setting up oxygen and acetylene cylinders experienced a small explosion and hose fire, leaving one with first-degree burns. The flash identifies inadequate flashback protection, bent hoses, faulty crimps, absent hot-work authorisation and unsuitable protective equipment. Lessons address arrestor placement and checking components after a flashback.
- 202521 Feb
Nitrogen Cylinder Rupture
A nitrogen cylinder charged to 2,400 psi ruptured at its base after rig crews positioned a cylinder rack for accumulator pre-charging. The rack was not connected to charge the accumulator. The rupture scattered the rack, debris and the remaining 11 cylinders around the immediate and port aft areas of the rig.
- 202524 Jan
BSEE Safety Alert 494 - Ruptured Nitrogen Cylinders
A nitrogen cylinder ruptured during preparations to pre-charge an accumulator system, causing three minor shrapnel injuries and equipment damage. BSEE attributes the failure to corrosive wall loss, aggravated by crevices, moisture and deteriorated rack coating. Recommendations address cylinder recertification, filling records, training, inspection and corrosion-preventive maintenance.
- 202417 Dec
Sudden disconnection of pressurised hose
During vessel maintenance, a hose disconnected while residual water was pumped from a cofferdam at approximately 5.9–6 bar. Nobody was struck or injured. The flash identifies absent whip arrestors, missed pre-use checks and an apparently worn coupling, and recommends secondary securing, coupling inspection and sufficient onboard spares.
- 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.
- 202414 Oct
Urgent inspection of pressurised carbon dioxide fire fighting systems
A specialist third-party inspection of a vessel’s carbon dioxide fire suppression system found Chinese-manufactured coins inserted in 21 of 24 main 45 kg cylinders. The coins blanketed high-pressure hoses, potentially impairing suppression effectiveness. The flash calls for immediate inspection of hose connections and rectification of anomalies.
- 20243 Sep
Nitrogen cylinder ruptured
A nitrogen cylinder ruptured on a drill rig floor, destroying its rack and propelling other cylinders up to 15 metres away. Severe base corrosion had escaped inspection. The flash highlights inspection access within cylinder quads and asks readers to check certification, condition, drainage and supplier inspection standards.
- 202429 Aug
Lifeboat air cylinder explosion on an empty installation
A lifeboat air bottle explosion was discovered on an uncrewed, shut-in offshore platform, with no injuries or known incident date. Inspection revealed corrosion beneath bottles seated in saddles. The flash discusses restricted inspection access, possible galvanic effects, depressurisation, improved bottle positioning and insulation between dissimilar materials.
- 202414 Aug
MSF: Serious hand injury – high pressure air
During a vessel fire drill, a crewmember assisting with breathing apparatus suffered a finger injury from high-pressure air released through a cylinder valve’s pilot vent hole. Surgical treatment was required. The flash relays MSF recommendations on connection tightening, leak checks, breathing checks and low-pressure alarm testing.
- 202416 Jul
Loss of pressure to diver’s primary air supply
A diver was recovered safely after primary air supply pressure fell. Surface testing traced regulator sticking to dried lubricant restricting the sensing assembly, particularly during light breathing. The flash discusses supervisory intervention, insufficient internal servicing, regulator rotation and increased six-monthly maintenance, testing and cleaning.
- 202430 Apr
Injuries to the eyes and face
Three crew incidents involve a screwdriver striking a cheek, an unplanned hydraulic-fluid release injuring a crane driver’s face and eye, and airborne debris entering an eye despite safety glasses. The flash discusses tool choice, written work instructions, refresher training, appropriate eye protection, engineering controls and stop-work authority.
- 202430 Apr
Near miss – lid on ash trash barrel blown off due to hot ash
A vessel waste-container lid was expelled by pressure from hot incinerator ash while a crew member attempted to release the compression ring. The lid fell 11 m to the main deck. The flash identifies unrecognised disposal risks and records installation of a goose neck vent and revisions to waste-management procedures.
- 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.
- 202419 Mar
High potential: sea water inlet pipe leakage in engine room
A vessel crew discovered seawater leakage from corroded air-conditioning condenser pipework near the hull while offshore. A cement box contained the leak before emergency dry-docking for repairs. The flash identifies missing documented condition checks and recommends regular inspection of ship-side valves and piping within planned maintenance.
- 202422 Jan
MSF: LTI – Engineer scalded
An engineer aboard a platform supply vessel suffered scalding burns when a cooling-water compensator burst during refilling after repair. The flash discusses sudden pressure increase, unsuitable temperature rating, likely material degradation and potentially inadequate pressure relief. Corrective measures address compensator suitability, installation checks, cooling before refilling and planned inspection and maintenance.
- 202321 Dec
KMCO LLC Fatal Fire and Explosion
Investigation of the fatal isobutylene explosion and fire at KMCO’s Crosby facility. Metallurgical testing established pressure-driven brittle fracture of a cast-iron y-strainer. The report examines thermal-expansion hazards, manual versus remote isolation, emergency-response roles and alarm use, identifying weaknesses in hazard evaluation and response that contributed to the incident and its severity.
- 202318 Dec
Failure of personal isolation procedures: Crane became damaged when it was used inappropriately
A crane aboard a vessel in dry dock was damaged when crew attempted to operate it during hydraulic repairs. Personal isolation had been used across several days by multiple people and removed for testing. The flash highlights inadequate risk assessment, the missing permit to work and restrictions on personal isolation.
- 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.
- 202327 Nov
Failure of proportional valve in saturation chamber control
A proportional valve feedback fault interrupted saturation diving, without injury or equipment damage. Automatic safeguards isolated the line and transferred control to a manual valve. Unauthorised dismantling obscured the origin of potentiometer damage; debris was also found. Lessons address manufacturer-led maintenance, critical spares, training and testing before diving resumes.
- 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.
- 202314 Nov
Flash Fire from Oxygen Regulator Leads to Burn Injury
A crew member suffered first- and second-degree wrist burns when an oxygen regulator burst during preparations for welding in platform decommissioning. The alert explains oxygen-system ignition hazards and recommends considering brass rather than aluminium fittings, controlled valve opening, contamination prevention, maintenance, training and protective clothing that keeps skin covered.
- 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.
- 202330 Oct
Fire extinguisher fails during pressure testing
A 13-year-old, 5 kg CO2 fire extinguisher rated to 200 bar failed at 196 bar during a scheduled hydrostatic test intended to reach 300 bar. Nobody was harmed. The flash discusses ageing and integrity, alongside actions concerning maintenance reviews, age-sensitive testing plans, inspection records and personnel training.
- 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 Aug
MSF: Air cylinder – high pressure discharge
A breathing apparatus cylinder’s pillar valve broke off while a crew member drained residual pressure before landing it ashore. Nobody was injured. The investigator considered impact from dropping the cylinder responsible. Recommendations address secure handling, slow controlled discharge, valve orientation and PPE; the owner is investigating excess-flow valves.
- 20233 Aug
Near miss with high pressure gas due to incorrect procedures
A crew preparing to pig high-pressure gas mains questioned a valve closure and identified that it would block the intended downstream flow. Work stopped and valves were restored to normal. Review found instructions based on an obsolete drawing; operations remained suspended pending correction, avoiding a compressor trip and possible downstream supply problems.
- 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.
- 202312 Jun
MAIB: High pressure oil leak causes a fire in the engine room
A vessel’s gearbox temperature probe was expelled by oil at 25 bar, spraying the engine room and igniting oil-soaked exhaust lagging. Crew contained the fires with foam. The flash identifies an insufficiently tightened compression fitting, describes a redesigned probe housing, and emphasises emergency preparedness and closer monitoring after construction or dry docking.
- 202325 May
LyondellBasell La Porte Fatal Chemical Release
This investigation examines the fatal chemical release during plug-valve actuator removal at LyondellBasell’s La Porte complex. Two workers died following exposure to acetic acid and methyl iodide. It compares similar incidents and examines valve design, pressure-retaining components, work procedures, training, isolation and pre-authorisation risk assessment.
- 202316 May
Differential pressure: Dummy choke ejected close to divers
A dummy choke insert was expelled by differential pressure during replacement work near two divers, who remained unharmed. The flash examines absent local venting, misunderstood pressure readings and unclear release expectations. It recommends explicit procedures and risk assessments, isolation training, confirmation of an open local vent and clarification of questionable instructions.
- 20233 May
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.
- 202320 Apr
BSEE: Person injured when safety mechanisms failed
An offshore sandblasting worker sustained head and shoulder injuries when a T-connection detached and a whip check failed. The flash discusses improper cable crimping, slightly corroded baling wire and stresses from horizontal hose positioning. Recommendations address additional securing, fitting orientation, pre-job inspection and depressurisation before valve adjustment where practical.
- 20234 Apr
Cut and bruise to right hand whilst pressure testing
A technician injured his right hand while removing a blanking flange after hydraulic hose pressure testing. Although the panel gauge indicated zero, a check valve trapped residual pressure. The flash recommends a ten-second delay after opening the main pressure valve, a second hose gauge, revised instructions and an updated task risk assessment.
- 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.
- 202313 Mar
Sudden and uncontrollable move of A&R head
During pipeline abandonment preparations aboard a vessel, an abandonment and recovery head was ejected from the pipe end while being aligned for welding. Crane support prevented it dropping, and nobody was injured. The flash identifies absent vent holes, unrecognised residual-water effects and unnecessary personnel exposure, encouraging reassessment of specifications and risks.
- 202327 Feb
Near miss: Foreign body in diver’s helmet, resulting in fall of gas pressure
A diver at 18 m experienced reduced breathing gas pressure. Bailout gas did not resolve the problem, but free flow restored suitable pressure. A plastic shard from a broken cleaning pot was found in the helmet regulator. The flash highlights pre-dive checks, cleanliness and the member’s introduction of spray bottles.
- 202317 Feb
Person Injured when Safety Mechanisms Failed
A sandblasting worker on a Gulf of Mexico offshore facility suffered head and shoulder injuries when a T-connection released and a whip check broke. The alert discusses improper crimping, potentially weakened baling wire and hose orientation, recommending improved securing, pre-job assessment, equipment checks and depressurisation when practical.
- 20239 Feb
Air hose connection failure
An air hose detached from a tugger winch coupling after use; nobody was injured. The flash describes an incorrect adapter, a homemade connection and improperly installed whip checks. It recommends manufacturer-specified hose-barb adapters, correctly positioned whip checks and adequately resourced planned maintenance.
- 202318 Jan
Diving instructor killed – incorrect valve threads
A diving instructor was fatally struck by a valve that detached from a cylinder during a dive. The cylinder’s G3/4 internal thread was incompatible with the valve’s M25x2 external thread. The flash advises members to follow IMCA guidance on diving cylinder and valve thread compatibility.
- 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.
- 202221 Dec
Kuraray Pasadena Release and Fire
Investigation of an ethylene release and fire during reactor startup at Kuraray’s Pasadena plant, injuring 23 workers. It examines unsafe atmospheric pressure-relief discharge, disabled interlocks, alarm flooding, conflicting operating instructions and restricted flare use. Recommendations address safe discharge design, worker exclusion, operating limits, training and independent process safety assessment.
- 202230 Nov
MAIB: A scalding injury
An engineer aboard a cruise ship suffered severe facial scalding after opening an isolated economiser’s drain valve before cooling was complete. Hot water and steam discharged and deflected upwards from a tundish. The flash highlights discharge-path exposure, caution when opening pressurised drain lines, and controlled valve operation using a correctly sized wheel key.
- 20221 Nov
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.
- 20223 Oct
BSEE: Unsecured Pressurised Hoses Result in Hand Injuries
This safety flash summarises two hose incidents during coil tubing operations: valve impact injured a thumb during pressure release, and a failed nitrogen connection caused a whipping hose to injure two workers. Recommendations address glove selection, depressurisation, hose restraint, valve checks, job safety analysis and stop-work authority.
- 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.
- 202229 Jul
Loy Lange Box Company Pressure Vessel Explosion
Investigation of a fatal steam-system pressure vessel explosion in St. Louis examines oxygen corrosion, incomplete repairs, water treatment and inspection failures. Metallurgical examination and thickness measurements underpin the findings. The report analyses regulatory oversight and process safety management, while noting that the pressure at rupture could not be determined.
- 202222 Jul
Flash fire on Oxygen gas quad hose
An oxygen supply change aboard a DSV was followed by a hose burst, explosion and flash fire. The technician closed valves after hearing an unfamiliar regulator noise. Investigation identified missing inlet filtration and accumulated rust particles contributing to ignition. A deck foreman extinguished the fire using dry powder.
- 202220 Jul
Bailout manifold failure
A diving bell bailout manifold failed under pressure with no divers inside. Forensic testing supported likely lateral loading from inappropriate securing, followed by stress corrosion cracking and internal corrosion. The flash describes suspended diving, bailout inspections, replacement with more robust assemblies and familiarity with planned maintenance tasks.
- 20222 Jun
Unsecured Pressurized Hoses Result in Hand Injuries 442
BSEE describes two Gulf of Mexico coiled-tubing incidents involving hose backlash and a failed nitrogen hose fitting, with hand injuries and an additional arm injury. Operators and contractors are advised to consider hose restraint, reduced pressure before valve manipulation, suitable gloves, fuller job safety analyses and stop-work intervention.
- 2022Jun
CHIRP Maritime FEEDBACK 67
Maritime incident reports examine risk acceptance through undocking damage, unsafe access over timber cargo, power and detection failures, collisions, cargo-control distraction, grounding, sinking and boiler repair. Commentary addresses testing, isolation, familiarisation and challenge culture. Additional material describes tug-use training and a pilot-boarding safety checklist.
- 202231 May
Surface decompression near-miss
A surface decompression near-miss involved an unintended chamber depth reduction from 12msw to 5msw following a SURDO2 dive. Divers remained symptom-free. The account identifies an incompletely closed exhaust valve and supervisor distraction, and describes revised operating responsibilities, venting and depth alarms, and camera monitoring.
- 202221 Apr
COBRA System – Hose coupling cross threaded
A diving safety flash describes leakage from a COBRA hose coupling that was cross-threaded and subsequently pulled free during helmet removal in the bell. It examines restricted access and reliance on a green pressure indicator, highlighting coupling alignment awareness, visible-thread checks and a requested supplier review of the coupling mechanism.
- 202221 Apr
Diver experienced an air flow restriction
A surface-supplied diver experienced restricted air flow at 23msw and the dive was aborted without injury. Investigation identified a needle valve that failed to open properly, with possible overtightening linked to premature equipment fatigue. Actions included valve replacement, revised pre-dive checks and operating procedures, and a team emergency debrief.
- 202222 Mar
Stored energy release: Two fatalities with tyres (IOGP)
Two fatal incidents during heavy-truck tyre maintenance involved sudden rim failures and released pressure. Both rims showed prior damage, and workers had not recognised their exposure to the line of fire. Corrective measures addressed tyre and rim inspections, deflation before removal, safer working methods and responses to warning signs.
- 202228 Feb
UK HSE: Liquid petroleum gas (LPG) leak
This safety flash describes a release of around 15 tonnes of LPG at Fawley refinery, undetected for around four hours. HSE identified excessive pressure for the valve and absent flow-discrepancy detection. Emergency personnel reset the valve. The account stresses maintaining protective layers against major incidents; no fire or injury occurred.
- 2022
CHIRP Annual Digest 2022
A compilation of maritime cases published during 2022, with commentary and supporting insight articles. Reports examine navigation, pilot boarding, mooring, towing, engineering maintenance and working conditions. Discussions address communication, bridge-team challenge, pressurised equipment, harness arrangements, risk assessment, permits and training, alongside examples of unsafe practice and effective intervention.
- 20218 Nov
Failure of COBRA contents pressure gauge
A COBRA contents gauge detached while a diver vented the unit before charging in a bell hangar. Examination attributed thread failure to dynamic damage, likely from impacts during use. Actions included gauge inspection and replacement, monthly fitting-integrity checks, third-party examination and serialisation to improve traceability.
- 20218 Nov
Failure of first stage regulator low pressure (LP) blanking cap
A diver’s bailout regulator leaked after a low-pressure port blanking cap failed. The dive ended and both divers were recovered safely. The flash records replacement of caps and O-rings, specified torque checks in work orders, and assessment of regulators used for more than ten years for possible replacement.
- 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.
- 202131 Aug
Near Miss – Damaged Rig Hose
A near miss during receipt of contaminated oil-based mud from a rig revealed detached hose lining trapped between connections. The flash identifies potential back-pressure hose failure and environmental consequences if flow were blocked, and calls for hose condition and certification checks, visual inspection before use and stop-work intervention.
- 202130 Jul
COBRA bailout system – guidance note
This safety flash summarises JFD’s investigation of lacquer blistering and excessive aluminium-neck corrosion in COBRA’s 2L composite cylinders. It distinguishes manufacturer assurances about lacquer defects from unresolved batch concerns, and advises external-condition checks whenever sets leave the dive system, with replacement and IDEST inspection before re-use where condition is questionable.
- 20219 Jun
Fatality – explosive failure of corroded fire extinguisher
A condemned, corroded cartridge-type dry powder extinguisher ruptured during discharge, striking a person and causing fatal head injuries. The flash describes inadequate appreciation of the danger and job planning, and sets out inspection, moisture-reducing mounting, qualified disposal and handling measures. It also suggests considering stored-pressure alternatives.
- 202124 May
Fatality Caused by Explosion of Corroded Fire Extinguisher
A person discharged a corroded cartridge-type dry chemical powder extinguisher previously condemned during an annual third-party inspection. Activation of its internal carbon dioxide cylinder was followed by rupture at the corroded base and an explosion. The unit struck the injured person, causing critical head injuries.
- 202130 Apr
Blind Shear Door Blown Off BOP Body
A blind shear ram door blew off a blowout preventer during pressure testing at 109 bars, below the planned 570 bars. It was found on an adjacent equipment container. Earlier inspection and ram replacement involved opening the doors; anti-rotation bars were not engaged during reassembly.
- 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.
- 202117 Mar
MSF: Air cylinder failure in lifeboat
A lifeboat air cylinder failed without warning, injuring three nearby crew members with blast debris. Investigation remained ongoing, with galvanic corrosion and prolonged submersion in bilge water identified as preliminary suspected causes. The correspondent recommends annual inspections for corrosion or wall damage and hydrostatic pressure testing at five-year intervals.
- 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.
- 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.
- 202029 Dec
Fixed well control equipment
NOPSEMA identifies gaps in thickness checking and tolerance verification for fixed mud gas separators, choke and kill pipework, and diverter pipework on mobile offshore drilling units. The alert discusses potential major accident consequences and recommends reviewing inspection and maintenance routines, with regular compliance audits.
- 20206 Dec
Air cylinders – Differences in working pressure and valve types
Incorrect SCBA cylinders were supplied, with different capacities and working pressures from those ordered. Compatible filling connections could allow reduced air capacity, while valve-head types were also incorrectly specified. The flash identifies supplier assumptions, purchasing checks and incomplete specifications, and calls for better communication between requesters, purchasing staff and vendors.
- 20206 Dec
UK HSE: Fatal incident using high pressure water jetting equipment
This safety flash describes a fatal injury during removal of paint residue from pipes with a high-pressure jet washer. The worker was struck by the flexi-lance end. HSE found missing pressure regulation and anti-ejection controls, alongside inadequate training and supervision, and prosecuted the company.
- 202016 Oct
Deficiencies in Process Piping Cause Gas Release Incidents
BSEE describes several Gulf of Mexico gas releases involving cracked welds, leaking gaskets and corrosion beneath insulation. The alert links incidents to quality assurance and mechanical integrity deficiencies, with vibration-related fatigue a possible contributor in one case. Recommendations address piping integrity programmes, leak detection, reporting, training and maintenance of compressors and pulsation dampeners.
- 20209 Oct
Trapped Pressure Ejects Rod From Chamber and Strikes Subsea Technician in the Face
A subsea technician was injured when trapped pressure ejected a sheared indicator rod during blowout preventer pressure testing. Previously damaged rods had remained unrepaired, and a workaround omitted their hazard. BSEE recommends considering OEM maintenance, proper work procedures, avoiding out-of-service equipment and recognising trapped pressure in job safety analyses.
- 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
Near miss: Sudden loss of air from diver bail-out bottle
A diver’s bail-out bottle emptied after a first-stage regulator diaphragm failed; he was recovered safely. Examination found weakened structural fibres and a hole despite recent servicing. The flash highlights subjective serviceability judgements, undefined replacement criteria and an enhanced planned maintenance requirement to replace the diaphragm alongside service-kit items.
- 202015 Sep
UK HSE: Two workers suffer multiple burn injuries
Two workers, including an apprentice, suffered life-changing burns during reassembly of high-pressure steam pipework following maintenance of a steam turbine driven pump. Steam was released uncontrollably at around 250°C. The investigation identified safe-system-of-work failures, including incomplete checks and verifications required by the steam isolation procedure.
- 20204 Sep
High potential DROPS near miss: Failed crane component
A crane’s man-riding brake casing failed during preparation, dropping components to the deck without injury. Investigation identified hydraulic overpressure and incorrectly set relief valves, with commissioning changes insufficiently evaluated. The flash describes isolation by blanking and recommends valve adjustment checks and reviews of change management, commissioning, competence and maintenance procedures.
- 202025 Aug
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.
- 202028 Jul
Sudden Uncontrolled Pressure Release
Hazard alert addressing sudden pressure releases during commissioning, decommissioning, maintenance and repair in the oil and gas industry. It identifies equipment integrity problems, changing conditions and unsafe work practices, and outlines employer and worker responsibilities for assessments, isolation, controlled depressurisation, safe procedures and avoiding released-energy paths.
- 202012 Jun
Serious injury caused by high-pressure washer
A supervisor suffered a thigh laceration during cleaning of a vessel thruster grating on a dock floor with a 250 bar water jet. Unexpected lance kick-back led the operator to turn and spray him. The flash highlights missing barriers, access restrictions, supervisory positioning, operator competence and pressure-rated protective equipment.