Topic
Barrier Management
Identification, performance and assurance of safety barriers.
Newest 100 Documents
All 119 in search- 202631 Mar
Ageing assets and life extension
Guidance on managing ageing assets and extending facility life through lifecycle planning, performance monitoring and integrity assurance. It presents a plan-do-check-act self-assessment framework, ageing modes analysis, competence arrangements and independent verification. Regulatory duties and health and safety representative involvement are discussed, alongside a Northern Endeavour corrosion example.
- 202631 Mar
ALARP in the context of well integrity guidance note
Guidance for titleholders on demonstrating reasonably practicable reduction of well-integrity risks within well operations management plans. It explains gross disproportion, recognised good practice, well-specific risk assessment and precaution under uncertainty. Supported arguments, proportionate analysis and continuing control effectiveness underpin the demonstration; no single methodology is prescribed.
- 202631 Mar
Hazard identification and risk assessment guidance note
Guidance for titleholders on assessing well integrity risks throughout the well lifecycle. It discusses subsurface assessment, independent design review, qualitative and quantitative analysis, FMECA, bow-tie methods and risk registers. Risk profiles inform monitoring and maintenance regimes, anomaly management, change assessment, and planning for well suspension and abandonment.
- 202631 Mar
Safety case content and level of detail guidance note
Guidance for preparing and assessing offshore petroleum facility safety cases explains appropriate content and proportionate detail. It covers facility descriptions, formal safety assessment, safety-critical controls, performance standards and integrated safety management systems. Emphasis falls on standalone evidence, workforce participation, assessment uncertainty and substantiated ALARP arguments rather than reproducing supporting documents.
- 202631 Mar
Staged WOMP submission process
NOPSEMA describes its preferred phased submission of well operations management plans, separating lifecycle management processes from construction, production and abandonment detail. The paper explains concept-selection and detailed-design submissions, risk registers, barrier acceptance criteria, change management and regulatory inspections, while allowing titleholders to retain their existing submission structure.
- 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.
- 2026Jan
Decommissioning
A regulatory checklist for temporary and permanent well abandonment under Subpart Q. Questions cover prior approval, isolation of open-hole zones and perforated intervals, cement plugging, conditional pressure testing, plug integrity, residual fluid density and wellhead removal. It also checks installation of two independent wellbore barriers, including a mechanical barrier.
- 20259 Dec
Human error risk reduction to ALARP information paper
This information paper suggests an ALARP-based approach to human error risk in the Australian offshore petroleum industry. It treats error as a barrier-defeating factor and outlines critical-task identification, error classification, performance-shaping factor analysis and control evaluation, distinguishing prevention from recovery and consequence mitigation.
- 20259 Dec
Human factors in accident investigations information paper
This information paper outlines a human-factors approach to accident investigations in the Australian offshore petroleum industry. It treats human error as a potential control failure mechanism rather than a root cause, recommending cognitive error classification, interviews to identify performance-shaping factors, barrier analysis and targeted corrective actions.
- 202526 Nov
Control measures and performance standards guidance note
Guidance for offshore facility operators on selecting and assessing controls for major accident risks and establishing verifiable performance standards. It addresses layered protection, common-mode failures, ALARP demonstration, critical operating parameters and lifecycle suitability, linking safety-case documentation with functional testing, monitoring, audit, review and contingency arrangements when controls underperform.
- 202531 Oct
Guidance note damage loss or removal of a technical or other control measure
Explains when operators must notify NOPSEMA of impaired technical or other control measures under dangerous-occurrence requirements. Reporting depends on failure to meet safety-case performance standards and whether those standards expressly permit the impairment. Illustrative examples distinguish reportable failures from permitted redundancy, maintenance tolerances and continued compliance.
- 202521 Oct
ALARP guidance note
Guidance for offshore petroleum operators on demonstrating ALARP through safety cases. It examines reasonable practicability, design choices, good practice, standards and proportionate risk analysis. It also addresses uncertainty, justification of control selection, performance standards and ongoing assurance, distinguishing major accident assessment from the broader health and safety responsibilities of the safety management system.
- 202519 Aug
Operational risk assessment guidance note
Guidance for offshore oil and gas operators on assessing temporary impairment of safety-critical controls and operation outside design limits. It explains hazard identification, qualitative or semi-quantitative risk evaluation, mitigation assurance, cumulative risk, responsibilities and restoration periods. Assessment must not justify predetermined continuation decisions or substitute for managing permanent changes.
- 2025Jul
Hydrocarbon Active Fire Protection
An inspection guide for offshore hydrocarbon fire protection, setting out regulatory expectations, success criteria and dutyholder scoring. It examines firewater pumps, ring mains, deluge coverage and chemical dosing, with emphasis on corrosion, marine growth, system availability, as-found testing and investigation of recurring blockages.
- 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.
- 2024Oct
Some short-cuts may cut lives short — Process Safety Beacon, October 2024
This bulletin examines procedural shortcuts through a fatal polyethylene reactor incident in Pasadena, Texas. It describes inadequate isolation, unenforced permits and cross-connected valve air hoses. Guidance stresses operational discipline, functioning safeguards and authorised assessment of changes, warning against treating temporary safeguard bypasses as routine practice.
- 202425 Sep
Tampering with approved safety devices
A client inspection found a homemade clamp holding open a self-closing valve on a vessel’s lubricating oil storage tank. Installed to save time, the modification had escaped routine checks. The flash highlights safety-device integrity, adherence to procedures and proper approval or management of change for equipment modifications.
- 202326 Dec
Wendland 1H Well Fatal Explosion
CSB investigates a fatal blowout and fire during tubing-head replacement at a Texas oil and gas well. It analyses inadequate well-control planning, ineffective hydrostatic and valve barriers, and ignition-source management. Recommendations address workover methods for underpressured reservoirs, well-history review and gaps in industry guidance and federal regulation.
- 202323 Oct
Bypass of Emergency Shutdown in Rented Equipment Results in Additional Risk to Personnel and the Environment
An offshore inspection found a rented generator/light plant powering a coiled tubing unit with its emergency shutdown bypassed following air intake hose removal. A functional test confirmed shutdown failure. The alert recommends considering rental-equipment checks, maintenance-record review, competence assurance and protective procedures when shutdown systems require bypass.
- 202229 Dec
Husky Energy Superior Refinery Explosion and Fire
Investigation of the Superior refinery explosion during fluid catalytic cracking shutdown. It examines air entering hydrocarbon equipment, missing steam-barrier and purge safeguards, eroded slide valves, procedural and training deficiencies, and brittle vessel fragmentation. Debris punctured an asphalt tank, escalating the event into fire; recommendations address transient-operation safeguards and emergency preparedness.
- 202213 Dec
Oil tank sight glass push buttons wired open
An engine-room visit identified oil-tank sight-glass push buttons deliberately held open with wire, defeating the gauge’s closing feature. The flash explains that accidental damage to the glass tube could allow tank contents to spill, creating slip and fire hazards and depriving equipment of its intended oil supply.
- 2022Sep
Operations Notice 84 - SCR2015 and SCR2005: The Dual Regime, Differences in Terminology and Interpretation, and Impact on Guidance Material
Explains the parallel offshore safety-case regimes for UK external and internal waters. It distinguishes major-accident definitions, safety and environmental critical elements, management systems and emergency plans under SCR2015 and SCR2005, and explains how duty holders should interpret existing guidance while terminology is reviewed.
- 20228 Jun
Human Factors information paper - Risk migration
Explains how operational trade-offs can gradually erode safety margins, using a well abandonment campaign involving offshore hydrocarbon gas venting. Examines deficient hazard assessment, equipment assurance and modification controls through systems theory, distinguishing possible explanations from verified findings. Introduces guided adaptability to support anticipation, coordinated responses and proactive learning.
- 202212 May
Process Safety Fundamentals – IOGP / Step Change
This safety flash summarises IOGP’s Process Safety Fundamentals through a Step Change in Safety learning pack suitable for safety meetings and toolbox talks. It highlights recognising change, stopping when work departs from expectations and investigating weak signals, alongside procedures, barriers, operating limits, isolation and ignition control.
- 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.
- 202228 Jan
Incorrect as-built drawing configuration
Divers investigating leaks at a subsea manifold followed approved procedures based on incorrect client information. Fault-finding revealed a different jumper configuration, leaving only one unproven barrier during intervention. Work stopped pending confirmation of safety; the client investigated without identifying how the error arose, and amended drawings were formally approved.
- 202121 Oct
Management of Hot Surfaces information paper
This information paper examines hot-surface ignition risks from non-electrical equipment in open process areas. It distinguishes hazardous area classification from assessment of large hydrocarbon releases, explains auto-ignition temperature and operating temperature limits, and discusses dispersion modelling, inspection assurance and evaluation of temperature exceedances against facility-specific standards.
- 202111 Aug
Step Change in Safety – Major Accident Hazard (MAH) Awareness
This safety flash introduces a Step Change in Safety mini-alert pack for proactive conversations about barriers to major accidents. Drawing lessons from oil and gas and other industries, the pack outlines accident circumstances and failures, with discussion points linked to the 7 Cs of Safety.
- 202128 Jan
The Offshore Audit, Monitoring and Review Inspection Guide
An offshore inspection guide for assessing duty holders’ audit, monitoring and review arrangements for major accident hazards. Templates examine assurance planning, auditor independence, competence, barrier coverage, report quality and closure of findings. It also addresses performance evaluation, organisational learning, regulatory success criteria and inspector judgement when assigning overall scores.
- 202121 Jan
Risk-Based Inspections of Subsea Leak Detection Technology Reveals Gaps in System Processes
BSEE reviews three subsea oil leaks and inspection findings showing weaknesses in leak-detection procedures and management processes. Operators and contractors are asked to consider clearer alarm response responsibilities, personnel training, system testing, configuration change control and ROV surveys. The alert emphasises investigating abnormal flow and learning from previous detection failures.
- 202119 Jan
Well Control - Issue 6
An offshore well-control inspection guide using questions, model answers and success criteria to assess operational arrangements. It examines conventional, high-pressure high-temperature and managed pressure drilling, including BOP assurance, kick detection, hydraulic modelling, fingerprinting, pressure relief, contingency procedures and crew training. Inspection scoring supports subsequent regulatory intervention planning.
- 202114 Jan
Structural response to fire and explosion
Guidance sets out expectations for demonstrating offshore installations’ structural resilience to fire and explosion. It addresses accidental loading, critical elements, temporary refuges, fire partitions, post-explosion door performance and escape tunnels. Particular considerations include floating structures, safety gaps, scaffolding congestion, passive fire protection and combined-operation safety cases.
- 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.
- 202021 May
Assurance of TEMPSC and associated systems guideline
NOPSEMA outlines expectations for assuring totally enclosed motor propelled survival craft at offshore petroleum facilities. The guideline addresses inspection, maintenance, waterborne testing and workforce competence, including hull integrity, buoyancy, deluge, propulsion and steering performance. It discusses limitations of alternative MODU drill arrangements and considers annual testing adequate for specified systems.
- 202015 May
Improper Installation of Safety Device
A heater treater incident involved readings above 1,000°F and a red-glowing stack before manual shutdown. The alert examines short thermowells and temperature indicators, Teflon tape impairing heat dissipation, and partially plugged arrestors. It recommends considering installation checks, scheduled maintenance and periodic inspection or replacement of safety devices.
- 20202 Mar
SECE Management and Verification - Version 2 March 2020
An inspection guide for assessing safety and environmental critical element management and verification on offshore installations. It examines barrier identification, performance standards, competence, change management and independent assurance. Detailed criteria address examination sampling, findings closure, scheme reviews, and interfaces with well examination and classification arrangements.
- 202020 Feb
Safety Alert 377 - Improperly Bypassed Safety Devices Poses Work and Environmental Hazards
BSEE describes an offshore inspection finding in which a zip tie improperly disabled a high-level safety device. The alert explains regulatory requirements and compromised protection, recommending that operators consider bypass procedures, monitoring, timely repairs, recurring checks, stop-work empowerment and investigation arrangements for potentially serious safety or environmental incidents.
- 20195 Jul
Structural Integrity
Inspection guidance for assessing offshore dutyholders’ structural integrity management through data, evaluation, inspection strategy and programme. It sets success criteria and enforcement performance ratings, addresses structural reassessment and ageing assets, and explains how classification surveys and risk-based inspection can support assurance of safety and environmental critical elements.
- 201912 Jun
Pryor Trust Fatal Gas Well Blowout and Fire
Investigation of an Oklahoma gas-well blowout and fire that killed five workers in the driller’s cabin. It examines underbalanced drilling, tripping methods, missed influx indications, disabled alarms, procedural and change-management deficiencies, blocked escape routes and unsuccessful blowout-preventer closure. Recommendations address drilling regulation, barrier assurance, alarm design and operating practices.
- 201819 Sep
Well Integrity (Operate Phase)
Inspection guidance for assessing well integrity during operation through management-system document review and role-specific interviews. It examines barrier verification, annulus pressures, operating and load limits, maintenance, change management and end-of-life review. Optional risk-assessment scrutiny covers qualitative assessment, QRA and FMECA, while enforcement guidance links inspection findings to compliance scoring.
- 201824 May
Arkema Inc. Chemical Plant Fire
Investigates organic peroxide fires at Arkema’s Crosby facility following Hurricane Harvey flooding. Examines loss of refrigeration and backup cooling, common-mode safeguard failures, flood-risk omissions in process hazard analysis, and evacuation decisions. Reviews extreme-weather guidance and recommends independent protection layers and improved emergency planning.
- 201725 Oct
Safety features of the Siemens Maxum Edition II gas chromatograph
This flash describes an explosion causing life-changing injuries to a technician when a Siemens Maxum Edition II gas chromatograph returned to service. Hydrogen had accumulated during hold status, and the automatic purge was not re-engaged. Users should review purge controls against the maintenance manual and discuss operating arrangements with manufacturers.
- 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.
- 20176 Jul
Well annulus leaks gas-lift inventory from failed instrument line
An instrument tubing failure released production-annulus hydrocarbon gas for 3.5 hours. Its position between the wellhead and gas-lift shutdown valve prevented shutdown from isolating the annulus inventory. The alert discusses small-bore integrity, secondary barrier vulnerability, two-barrier practice and recommended shutdown-valve placement and activation.
- 201725 May
Dangerous modifications found within a gas valve unit room
A safety flash describes methane exposure in an LNG carrier’s gas valve unit room following damage to an expansion bellows O-ring. An unauthorised hose arrangement could likely have impaired methane detection. The account highlights ventilation and gas monitoring arrangements, and the US Coast Guard’s recommendation for engineering review and approval of modifications.
- 20173 May
ExxonMobil Torrance Refinery Explosion
CSB investigates the Torrance refinery electrostatic precipitator explosion during FCC Safe Park operation and expander isolation. It examines failed catalyst and steam barriers, slide-valve erosion, hydrocarbon backflow, inadequate procedures and detection, and ignition within the energised precipitator. Recommendations address isolation, safeguard assurance, maintenance, operating modes and equipment siting.
- 201620 Apr
Macondo Blowout and Explosion
Volume 3 examines human and organisational factors in the Macondo incident, including temporary abandonment, negative-test interpretation and riser gas handling. It analyses barrier assurance, change management, incident learning, process-safety indicators and corporate governance, contrasting written policies with operational practice and proposing improvements to major accident prevention.
- 2016Mar
Safety Device or Control Device? — Process Safety Beacon, March 2016
This bulletin distinguishes routine process control from independent safety protection through a steam-locomotive example and a tank-overflow incident. It explains how reassigned operator duties turned a backup shutdown into primary control, and recommends clear procedures, training, calibration and scheduled testing of safety devices.
- 20145 Jun
Macondo Volume 1 Final Report
Volume 1 examines the Macondo blowout during temporary abandonment aboard Deepwater Horizon. It explains deepwater drilling, cement barriers, drilling-fluid pressure and positive and negative pressure tests. The report describes inadequate barrier assurance, separator overload and drillpipe buckling that inhibited BOP sealing, followed by explosions, fire and fatal injuries.
- 20145 Jun
Macondo Volume 2 Final Report
Volume 2 examines the Deepwater Horizon blowout preventer’s failure to seal the Macondo well, including off-centre drillpipe buckling, miswired solenoid valves and emergency-system assurance gaps. It uses forensic testing and modelling to assess barrier performance, comparing regulatory approaches and recommending lifecycle management and independent verification of safety-critical elements.
- 201220 Aug
Helideck Obstruction Hazard: Marking and Notification
Following a fatal helicopter crash, this alert examines helideck obstruction identification, closure marking and notification to aviation providers. A pilot attempted to land on an unmarked platform helideck apparently obstructed by a jackup. The reasons for the landing attempt remain unknown; management marked the helideck closed afterwards.
- 20124 Apr
Bypassing of storage tanks safety features
This safety flash relays NOPSEMA’s alert about intentional defeat of safeguards on machinery-space oil and fuel storage tanks. Reported practices included holding spring-return valves open using zip ties and other means. The tanks contained hydrocarbons; no resulting release or injury is described.
- 201222 Feb
Bypassing of storage tank features
Inspections identified bypassed safety features on oil and fuel storage tanks, including sight-glass valves held open with zip ties or homemade clips. The alert explains potential inventory release if sight-glass integrity fails, outlines SOLAS requirements, and recommends safeguarding devices, meeting safety-case commitments and considering alternative level measurement arrangements.
- 201217 Feb
Report - Montara investigation: Volume one
Volume one of an expert witness investigation into the Montara hydrocarbon release sets out the appointment, factual timeline and assessment framework. It examines well construction and suspension, cement isolation, barrier requirements, regulatory comparators and risk-management methods, introducing WAiT integrity assessment and documenting limitations in the supplied records.
- 201217 Feb
Report - Montara investigation: Volume three
Third volume of an expert witness investigation into the Montara hydrocarbon release. It reconstructs the operational timeline, charts H1-ST1 integrity during construction, suspension and re-entry, and evaluates barrier acceptance and verification. Technical responses examine corrosion caps, annular seals, cement isolation, change management and opportunities for risk assessment.
- 201217 Feb
Report - Montara investigation: Volume two
The second volume of an expert witness investigation examines nine issues surrounding the Montara hydrocarbon release. It assesses cement volumes, slurry properties, over-displacement, casing-shoe testing and corrosion-cap handling. Documentary analysis considers well suspension, barrier adequacy and programme changes, with proposed improvements to verification, contingency procedures and risk assessment.
- 2011Dec
Caps and Plugs - One Day You Will Miss Them! — Process Safety Beacon, December 2011
Falling scaffolding debris opened a quarter-turn vent valve, releasing flammable material that ignited, killing one worker and seriously burning two others. The bulletin explains the importance of caps, plugs and additional containment barriers, checking missing closures, considering valve design and handle placement, and reviewing modifications through management of change.
- 2010Jul
Passive Safety Equipment — Process Safety Beacon, July 2010
This bulletin explains how passive safeguards provide protection through their construction rather than sensors or moving parts. Drawing on earlier issues about insulation, fireproofing and containment dikes, it stresses continuing inspection and maintenance, understanding each safeguard’s function, recognising damage and arranging repairs.
- 20106 Apr
Failure of pipeline emergency shut-down valve
HSE alerts operators to a spring-return pipeline emergency shutdown valve that failed open, disabling platform isolation. Initial indications linked retaining-rod failure to corrosion; released springs and an end plate presented stored-energy hazards. It calls for prompt inspection, conditional temporary restraints, actuator performance testing, coating and seal maintenance, and review of corrosion-resistant designs.
- 2010Mar
A guide to the Offshore Installations (Safety Case) Regulations 2005
Explains the 2005 offshore safety-case regulations, including duty-holder responsibilities, submission, acceptance and continuing review. Covers major-accident risk evaluation, contractor management, independent verification of safety-critical elements, well-operation notifications and dismantling revisions. Distinguishes notifications from accepted safety cases and explains that acceptance does not guarantee installation safety.
- 2009Dec
The Bhopal Tragedy – 25 Years Ago — Process Safety Beacon, December 2009
This anniversary bulletin revisits the Bhopal methyl isocyanate release, with an accompanying 2004 Beacon. It describes water contamination, an exothermic reaction and inadequate safety systems, while retaining uncertainty over the water source. Lessons address reactive hazards, safe relief discharge, maintenance, change evaluation and emergency procedures.
- 2009Jun
DOE Human Performance Improvement Handbook, Volume 1
This DOE handbook explains human performance through individual behaviour, workplace conditions and organisational influences. It combines error prevention with layered control assurance, examining cognitive limitations, investigation, operating-experience learning and safety culture. Leadership practices, just culture and performance improvement methods are developed through conceptual models and illustrative accident accounts.
- 2008Oct
2008-053 Investigation of Blowout, Main Pass Block 91 Platform A, OCS-G14576, August 23, 2007, Gulf of Mexico, Off the Louisiana Coast.
Investigation of a gas blowout at Main Pass Block 91 Platform A, followed by platform subsidence. The report examines sustained casing pressure, poor cement quality, diagnostic testing and procedural communication failures. It describes unsuccessful kill attempts and relief-well abandonment, while leaving the precise casing-failure mechanism unresolved and recommending abandonment of remaining wells.
- 2008
Verification during decommissioning and dismantling
Guidance on revising offshore verification schemes during decommissioning and dismantling as safety-critical elements and specified plant change. It explains consultation with the independent competent person, phase-based risk assessment, revision before changes, record retention and consideration of additional safeguards when barriers deteriorate. It also clarifies when installation status ends.
- 2007Nov
Key Programme 3 (KP3) Installation Integrity
HSE’s KP3 report evaluates offshore asset integrity through maintenance-management inspections and safety-critical system tests. It examines maintenance backlogs, deferrals, corrosion, ageing assets and leadership weaknesses. Traffic-light assessments identify uneven performance, with particular concerns over temporary-refuge ventilation shutdown and deluge reliability, alongside examples of improved planning and assurance.
- 2007
Advice on acceptable criteria for damaged passive fire protection (PFP) coatings
Guidance for offshore duty holders on assessing damaged passive fire protection coatings against fire threats and structural criticality. It explains cementitious and epoxy intumescent coating behaviour, three damage severity levels and a five-step evaluation method. Repair priorities and manufacturer procedures are considered alongside water ingress, disbondment, cracking, corrosion and erosion.
- 2006
Developing process safety indicators - A step-by-step guide for chemical and major hazard industries
A six-stage guide to developing process safety performance indicators for major-hazard organisations. It links leading and lagging measures to critical risk control systems, sets tolerances, and addresses reporting and management review. A worked chemical-storage example demonstrates indicator selection and prioritisation.
- 2006
Testing regime for offshore TR-HVAC fire dampers & TR pressurisation requirements
Guidance for offshore duty holders on assuring temporary refuge HVAC fire-damper performance and maintaining protective pressurisation. It examines full-loop testing, closure indication and timing, detector arrangements, pressure-decay measurement and leakage inspection. Inspection findings inform recommendations on test frequency, access and maintenance records, with reference to relevant offshore regulations.
- 200515 Dec
Safety Alert 235 - Multiple Cable Transit Failures
This alert reports preliminary findings on failed multiple cable transits at Thunder Horse following Hurricane Dennis. Water moved between access spaces through the transits, with failures in blank-block sections. The original influx and listing cause remained undetermined. MMS recommends checking installation and pressure ratings pending verified investigation findings.
- 200518 Feb
Safety Alert 18 - Well-Control Equipment Circumvention
An MMS alert describes loss of well control during workover/completion after completion-fluid pumping stopped and a tubing hanger lockdown pin was removed, bypassing blowout prevention. Seawater and hydrocarbons escaped. It distinguishes direct from possible contributing causes and recommends improved hanger-landing procedures, well-control training and job safety analyses.
- 2004Dec
Bhopal - a tragic event — Process Safety Beacon, December 2004
This bulletin revisits the Bhopal methyl isocyanate release twenty years later. It describes water entering storage, rising temperature and pressure, and inadequate safety systems, while noting uncertainty over the water source. It emphasises chemical reactivity, emergency procedures and understanding worst-case scenarios and protective layers.
- 200424 Jun
Safety Alert 221 - Hanger Failure and Ejection Lead to Well Control Incident
During a workover, hanger hold-down pins sheared at 6,150 psi, ejecting the hanger and tubing. Investigation identified inadequate pin engagement caused by a design flaw. The alert identifies affected Cameron products, recommends multiple well barriers and advises operators to consider shear rams for wells presenting unusual control problems.
- 199619 Aug
Safety Alert 168 - Twisted Valve Stem and Ineffective Level Safety High Result in Oil Spill
An oil spill followed separator cleaning when a twisted ball-valve stem left the drain partially open despite its handle position. Density differences prevented the sump tank’s level safety high from actuating. The alert recommends periodic valve holding checks where operationally feasible and reviewing atmospheric-tank level protection against this upset condition.
- 19761 Sep
Safety Alert 49 - Oil Spill, Safety Equipment Failure
An offshore production platform spilled oil after transfer pumps gas locked and several high-level shutdown safeguards failed. The alert describes flow through scrubbers and a skim pile into the Gulf, and records operator actions addressing device operation, standpipe positioning, simulated-level testing and pump gas locking.
- Undated
ROV Descended to Seabed During Recovery After Umbilical Winch Free-Spooling
Investigation of an ROV recovery incident aboard Deepwater Atlas in which an umbilical winch free-spooled and the vehicle descended to the seabed. Contractor and manufacturer analyses attributed gear damage to inadequate lubrication. Emergency stopping depended on the failed gearing. The report examines maintenance evidence, crew response and limitations of the investigation.
- Undated
Satellite Umbilical Termination Failure and Hydraulic Line Ruptures
BSEE investigates a satellite umbilical termination failure affecting the MC 208/209 subsea well. Hydraulic lines ruptured, while fail-safe shutdown successfully shut in associated wells. Findings identify excessive loading on the connection plate and failure of temporary buoyancy rigging retained for long-term use. ROV inspection and recovered-component examination informed the investigation.
- Undated
Four Pollution Events on Offshore Production Platform
Investigation of four pollution events at SP 49-A platform during November and December 2006. The report describes treatment-system upsets, an unattended pig-trap valve and bypassed emergency shutdown safeguards. It identifies training, supervision, unsafe practices and fatigue as probable and contributing causes, and recommends an audit emphasising facility-specific operator training.
- Undated
16-May-2026 0915 G19996 MC 773 Damaged/Disabled Safety Systems
An investigation examines loss of power at Devil’s Tower following a turbine overspeed sensor failure and an emergency generator’s faulty electronic control module. Production stopped and non-essential personnel were evacuated. A rental generator supported restoration. The report identifies obsolete parts and outdated troubleshooting software, with no injuries or pollution reported.
- Undated
BP - Ula - Investigation of hydrocarbon leak
Investigation of a hydrocarbon leak on Ula P attributes valve bolt fracture to chloride stress corrosion following exposure to produced water. It examines inconsistent material certification, assessment of earlier seepage, shutdown failures, ignition isolation and fire protection. Emergency planning and clean-up assessments also showed deficiencies; no people were injured.
- Undated
ConocoPhillips - Eldfisk - Investigation of emergency shutdown and acute oil spill
Investigation of emergency shutdown and an ensuing oil spill at the Eldfisk complex in August 2014. It examines output-card failure, safety-system design, production restart with an open blowdown valve, drainage limitations and operator interfaces. Findings address restart verification, maintenance testing, modification documentation and delayed personnel accounting.
- Undated
COSL Drilling - COSLInnovator - Investigation of incident with fatal consequences
Investigation of the fatal wave-impact incident on COSLInnovator examines air-gap calculations, hydrodynamic model testing and design decisions concerning horizontal wave slamming. It assesses accommodation damage, window attachments, water ingress and emergency mustering. The report identifies design-basis shortcomings while retaining uncertainty about the damaging wave and incident-time motions.
- Undated
Engineered Safety and Environmental Aspects of Well Construction and Fracturing Design
Presentation on engineering well construction and hydraulic fracturing for pressure containment and groundwater protection. It covers casing and liner design, cement evaluation, treating-line ratings and testing, staged pump shutdowns, relief arrangements and wellhead valves. Surface planning addresses fluid storage, spill berms and logistics, alongside examples of fracturing-fluid ingredients.
- Undated
Equinor - Deepsea Bollsta - investigation of well control incident
Investigation of a gas release during permanent well abandonment on Deepsea Bollsta at Troll. Casing cutting released reservoir gas behind the casing, causing minor injury to one person and equipment damage. The report examines cement barriers, ultrasonic logging interpretation, BOP operation, gas detection, ventilation pressures and escape difficulties.
- Undated
Equinor - Hammerfest LNG - investigation of fire
Investigation of the Hammerfest LNG turbine air-intake fire examines likely pre-filter auto-ignition during hot-oil circulation with the turbine stopped. Site inspections, interviews, fire tests and CFD modelling inform findings on filter maintenance, undocumented operating practices, organisational capacity, detection and firewater coverage, alongside evacuation and vessel-assisted firefighting.
- Undated
Equinor - Hammerfest LNG - Order after investigation of hydrates in safety valves
Investigation of prolonged overpressure-barrier impairments at Hammerfest LNG on Melkøya. Hydrates prevented some pressure safety valves from functioning, while the affected total remained unknown. The report examines heat tracing and insulation, maintenance and testing interfaces, delayed risk assessment and management follow-up, and corrective measures installed during plant shutdown.
- Undated
Equinor – Aasta Hansteen – investigation of gas leak
The PSA investigates a gas leak from a rupture-disc holder in Aasta Hansteen’s high-pressure flare system. It examines disc installation, bolt clamping, piping alignment and inconsistent flare-valve opening requirements. The combined leak rate was assessed as exceeding 0.1 kg/s. A subsequent similar incident leaves the relative importance of causal factors uncertain.
- Undated
Equinor – Hammerfest LNG – investigation of gas leak
Investigation of a cooling-medium leak during insulation removal at Hammerfest LNG. The report examines an unusual left-hand-threaded bleed plug, incomplete valve closure, gas-detector positioning and impairment, and emergency intervention. Leakage lasted about 6.5 hours. Findings address equipment training, operating documentation, trapped pressure and response arrangements.
- Undated
Equinor – Mongstad – investigation of fire
Investigation of a thermowell-flange leak and fire at Mongstad refinery on 3 July 2022. Hydrogen-rich naphtha auto-ignited following release. The report examines flange design, insulation, maintenance omissions, risk analysis and emergency response. Nobody was injured. Material investigations did not establish the underlying cause unambiguously.
- Undated
Equinor – Njord A – investigation of oil spill
Investigation of an oil spill from Njord A through its produced water system. A manually fixed valve and failed low-level shutdown allowed discharge for two hours and twenty minutes. The report examines gamma-based level measurement, calibration and testing deficiencies, shared control and shutdown dependencies, and missing valve travel limitation.
- Undated
Equinor – Sleipner A – investigation of incident with short circuit and fire pump breakdown
Investigation of a transformer short circuit and consequential fire-pump incident on Sleipner A. Interviews and document review examined winding weaknesses, failed flexible coupling, maintenance omissions and ineffective incident-learning follow-up. The report also assesses diesel shut-off arrangements, emergency training and fire protection. Nobody was injured.
- Undated
Equinor – Sleipner B – investigation of fire
This revised investigation examines the Sleipner B variable speed drive fire on 22 October 2024. The initiating cause remains uncertain. It analyses electrical supply dependencies, unavailable firewater, smoke containment, ventilation, maintenance and emergency response, identifying seven non-conformities. Material damage and prolonged production shutdown occurred, without reported injuries or discharges to sea.
- Undated
Equinor – Statfjord A – investigation of oil leak after overpressurising storage cell
Investigation of sludge-cell overpressurisation at Statfjord A during filling with a ballast-water valve closed for maintenance. Concrete cracking released an estimated 150 cubic metres of oil and sludge to sea. The report examines inadequate overpressure barriers, isolation arrangements, alarm response and documentation that failed to reflect changed cell use.
- Undated
Equinor – Statfjord B – investigation of gas leaks
This investigation examines two gas leaks during Statfjord B’s restart after a turnaround on 23 May 2022. External corrosion compromised carbon-steel blowdown lines. Findings address deferred surface maintenance, inadequate visual inspection and pipe identification, outdated risk-based inspection assessments, startup planning and emergency response, including missed deluge activation.
- Undated
Equinor – Tjeldbergodden – investigation of turbine breakdown and fire
Investigation of a steam turbine breakdown and fire at Equinor’s Tjeldbergodden methanol plant. Failed medium-pressure steam isolation during process shutdown allowed backflow and overspeed. The report examines valve criticality, temporary repairs, missing functional tests and operating documentation, alongside firefighting and evacuation arrangements. No physical injuries were reported.
- Undated
Equinor/Island Offshore – Oseberg H/Island Clipper – investigation into loss of gangway
Investigation of two gangway failures at the Oseberg H–Island Clipper interface in 2025. Hydraulic coupling failures disabled gangway functions and the primary evacuation route, requiring helicopter evacuation without injury. The report distinguishes a likely May material defect from October assembly deficiencies and examines shared hydraulic dependencies, change management and emergency drills.
- Undated
Esso – Slagentangen – investigation of naphtha leak
Investigation of a naphtha leak at Esso’s Slagentangen refinery attributes pipe perforation to corrosion under insulation and missing inspection coverage. It examines risk-based inspection, shutdown decisions, gas detection, possible benzene exposure and emergency response shortcomings. Drainage contained the release without discharge to the natural environment.
- Undated
Gassco - Kårstø - Investigation into gas leak
Investigation of a gas leak at Kårstø attributes instrument-fitting fracture to bending fatigue in an unsupported manometer assembly. The release lasted 9.5 hours without injuries. Materials testing and modelling inform findings on mechanical support, maintenance, incident learning, emergency depressurisation and shutdown arrangements, alongside functioning detection and ignition-control barriers.
- Undated
Good practice list
This compilation presents good practices drawn from KP3 inspections, acknowledging uneven adoption and poor sharing across companies. Examples address offshore asset integrity, maintenance planning, safety-critical element assurance, risk assessment and performance monitoring. It also highlights workforce competence, management engagement, defect registers and communication between offshore personnel and onshore technical authorities.
- Undated
Health and Safety Regulatory Regime in the UK
HSE presentation explaining regulation of onshore oil and gas through well notification, independent examination, safety documentation, operational reporting and enforcement. It follows well integrity from design to abandonment, including cement barriers and verification methods, and outlines safeguards for hydraulic fracturing and protection against respirable crystalline silica exposure.
- Undated
Human and organisational factors in well control audit report
This multinational audit examines human and organisational influences on well control across operators, drilling contractors and service companies. Common interview questionnaires assess interfaces, competence, procedures and company coordination. Findings highlight variable bridging documents, limited incident learning and well-control indicators, alongside generally clear displays and assurance of driller shut-in authority.