Control
Lockout and Tagout
Locking and tagging isolations to prevent unintended re-energisation.
Newest 100 Documents
All 112 in search- 202617 Mar
Working in a confined space without a Permit to Work
A safety walk-round identified crew removing pipes inside a sewage tank without a confined-space entry permit. Work was stopped and treated as a near miss. The flash examines assumptions arising from the tank’s clean appearance, missing entry safeguards and inadequate hazard identification, and stresses following procedures and confirming confined-space work with supervisors.
- 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.
- 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.
- 202518 Jun
Lock out/Tag out and unauthorised electrical connections/disconnections
This flash describes missing electrical and mechanical lockouts identified during a vessel engine-room audit, alongside unauthorised electrical disconnections and bypasses. It emphasises suitable lockout devices, documented approval of temporary modifications, restoration checks and clear handovers. Possible links to dynamic positioning trials are presented as assumptions rather than established causes.
- 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
Positive findings and good practices
This safety flash shares positive vessel practices covering machinery lockout/tagout, mooring-deck markings and engine-room housekeeping. It highlights protection against unexpected energisation, recommends warnings about potential snapback across the entire mooring deck, and describes how orderly engine rooms reduce slip, trip and fire hazards while supporting maintenance.
- 2024Aug
CHIRP Superyacht FEEDBACK 7 (August 2024)
Six superyacht reports examine tender lifting-point failure, fouled anchors near a lee shore, an open shell door, a fall during window cleaning and unsafe diving arrangements. Commentary emphasises thorough risk assessment, properly completed work permits, reliable equipment, crew communication and isolation during underwater maintenance.
- 202422 Jan
UK MAIB: Deep fat fryer fire
A shipboard galley fire followed restoration of power to two deep fat fryers drained for cleaning. Overheated elements ignited fat-saturated food residues before thermal protection disconnected power. Crew extinguished the fire without damage or injury. Lessons address lockout/tagout, equipment readiness, electrical supply checks and practised emergency response.
- 2024
CHIRP Maritime FEEDBACK 75 (Summer 2024)
Confidential maritime reports examine commercial pressure over damaged anchors, laundry and cargo fires, machinery and mooring hand injuries, inadequate provisions and a grounding. Commentary addresses escalation of concerns, bridge coordination, laundry practices, dangerous-goods stowage, machinery isolation and guarding, and keeping hands clear during mooring.
- 202314 Dec
BSEE Safety Alert 478 - Inadequately Maintained Electrical Connections and Compromised Wiring Integrity (6)
This alert examines three electrical incidents involving a loose generator cable connection, damaged heat-trace insulation with improper grounding, and rainwater ingress into generator wiring. It recommends that operators consider routine maintenance, training, emergency-response rehearsals, improved cable procedures, lockout/tagout reinforcement and periodic infrared inspections.
- 20236 Dec
UK MAIB: Electrician injured in explosion
An electrician suffered serious burns aboard a ship after a spanner bridged live switchboard conductors, causing a short-circuit and arc flash. The flash highlights unfamiliarity with the circuit-breaker assembly, disregarded instructions, unplanned work without a permit or lockout/tagout, and unsuitable tools and protective equipment.
- 20233 May
Equipment starts unexpectedly
Three mechanics were maintaining a high-voltage AC unit under lockout/tagout when it restarted unexpectedly. A broken circuit-breaker handle linkage had prevented shutdown. Nobody was injured. The flash highlights verification of de-energisation and correct energy-source isolation, including when equipment is upgraded or modified.
- 202316 Feb
LTI: Person crushed in watertight door
An electrician suffered severe crushing injuries when a vessel’s watertight door opened during proximity-sensor adjustment. A damaged selector switch enabled the opening command, while a leaking ball valve failed to isolate the hydraulics. The flash highlights absent work authorisation, lockout and task analysis, and recommends adequate replacement spares.
- 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.
- 2023
CHIRP Fisher Feedback Autumn 2023
CHIRP’s first commercial fishing newsletter examines pot-line propeller fouling, a conveyor fingertip injury, a lone fisher falling overboard, failed trawl hoisting, a ferry collision and recovered unexploded ordnance. Case commentary discusses maintenance isolation, work communication, wire-rope inspection, harbour navigation and personal emergency signalling and self-rescue arrangements.
- 2023
CHIRP Maritime FEEDBACK 70 (Spring 2023)
This maritime incident digest examines single points of safety failure through reports of grounding, steering loss, unsafe fendering, towing difficulties, coercion, obstructed access, collision, maintenance injury, lifting failure and battery fire. Commentary addresses bridge teamwork, workload, isolation, inspection access and emergency arrangements, with practical lessons for vessel crews and managers.
- 2023
MAIB Safety Digest 2/2023
A multi-case marine safety digest draws lessons from navigation incidents, fires, falls, cargo lifting, mooring injuries and fishing casualties. Case analyses examine communication, electrical work, lifejacket use and recovery arrangements. Reproduced bulletins and flyers address fuel-hose modifications, liferaft servicing, carbon monoxide poisoning and fatal man-overboard incidents.
- 202226 Jul
Equipment found live: drawings incorrect for Lock-out/Tag-out
A foreman checking for dead found energised control oil pump motor space heaters omitted from lockout/tagout arrangements. Incorrect drawings and a breaker schedule identified the wrong circuit. Work stopped and documentation and isolations were amended. Nobody was harmed; lessons emphasise comprehensive lockout/tagout and checking for dead.
- 202220 Jun
High potential: electric shock near miss
An engineer received a minor shock while troubleshooting a faulty 690V motor using a multimeter. The junction-box cover touched one phase during replacement; no injury was confirmed. The flash examines an unassessed change to live electrical work, missing isolation and authorisation, inadequate gloves, and subsequent requirements for crew discussion before work.
- 20221 Apr
Safety Alert 436 - Arc Flash Injury During Generator Hookup
An electrician sustained a second-degree arm burn while reconnecting a diesel backup generator to a live bus. The alert identifies shortcomings in task hazard analysis, arc-flash protection and lockout documentation, with breaker defects contributing to the incident. It presents measures for operators and contractors to consider, including assessments, qualification checks and breaker condition reviews.
- 202228 Feb
Permit to Work and Isolation procedure not followed
An electrician replacing fuses in a live 930V DC vessel drive cabinet experienced an arc flash without injury. The flash examines absent work permits, unsecured and untagged isolation, inadequate procedures and failure to check isolation before work. Actions focus on reviewing work controls and following workplace instructions.
- 2022
MAIB Safety Digest 1/2022
This multi-case marine digest examines collisions, groundings, machinery failures, fires and people entering the water across merchant, fishing and leisure vessels. Lessons address bridge teamwork, maintenance isolation, pilot-ladder securing, risk assessment and emergency preparedness. Reproduced bulletins and flyers discuss vehicle-deck crushing, collision avoidance and fishing-vessel survival.
- 202122 Sep
Electrician suffered flash burn to hand
An electrician suffered a hand flash burn while checking insulation on a 690-volt bus bar aboard a vessel in dry dock. The switchboard became live after an unguarded status switch changed and the power management system closed a breaker. Lessons address isolation, shipyard work permits, supervision and communication.
- 202113 Sep
Yawing of wind turbine nacelle placed ship in line of fire
A turbine crew yawed a nacelle without communicating with the vessel bridge, placing a blade in the ship’s intended astern path after personnel and cargo transfers. The vessel moved clear without further event. Actions strengthened communication protocols and procedural controls, requiring positive confirmation that vessels were clear before nacelle movement.
- 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.
- 202127 Apr
Safety Alert 420 - Employee Injures Hand in Rotating Equipment
A mechanic responding to an after-hours compressor shutdown entered the unit while its cooling fan was slowing. Placing his hand on the belt pulled him into a sheave, fracturing two fingers. The alert recommends considering reviews of after-hours work controls, including job safety analysis, lockout/tagout and stop-work practices.
- 202124 Feb
Failure to Follow Procedures Results in Pollution Incidents
BSEE describes two Gulf of Mexico pollution incidents involving open valves during well workover and synthetic-based mud transfer. The second investigation remained ongoing, with preliminary findings indicating procedural non-compliance. Recommendations address flow-path understanding, valve labelling, physical verification before start-up, defined responsibilities and lockout/tagout barriers for overboard mud-system components.
- 20219 Feb
Electrical Fire Damages Equipment in Motor Control Center
An offshore platform motor control centre fire followed circuit-breaker engagement. Analysis identified loose or damaged bus-bar fasteners, damaged insulation and dust that likely caused an arc. BSEE recommends considering inspection and maintenance procedures, thermography, insulation-resistance and polarisation-index testing, torque checks and component replacement schedules.
- 202010 Nov
Two incidents with electrical installations with potential for a fire
Two electrical incidents concern fat-contaminated galley sockets causing an earth fault and potential fire, and a minor machinery-space fire associated with lost terminal continuity. The flash describes socket isolation, lockout and cleaning, dry chemical powder extinguishing, and routine checks of electrical connections and terminations during planned maintenance.
- 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.
- 202031 Mar
Agitator started moving during mud tank cleaning – leading to injury
A contractor cleaning a vessel’s mud tank was struck by an unexpectedly starting agitator, suffering bruising and a broken rib. The flash examines omitted isolation, inadequate risk-assessment review and unclear departmental and contractor responsibilities. Actions address physical verification, lockout and tagging, isolation certification and improved communication.
- 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.
- 202019 Feb
Electric shock resulting in burn
An ROV technician sustained an arm burn from electric shock while bleeding a hydraulic filter in a technical workshop. A cut cable routed through a water drain remained live from a separate transformer despite local lockout. The flash recommends proper cable disconnection, documented modifications, formal change management and supervisor handover.
- 201930 Sep
Near miss – Diving operations while alongside
A main engine started while a diver cleared bow-thruster debris in a dockyard; the bridge immediately shut it down and the diver escaped unhurt. The flash identifies failures in communication, permits, lockout/tagout and risk assessment, and recommends physical isolation and verified control-of-work arrangements before diving.
- 2019Aug
Hidden Hazards! — Process Safety Beacon, August 2019
This manufacturing safety bulletin addresses hidden chemical and energy hazards before opening process equipment. An employee injury involving undocumented piping containing sulphuric acid illustrates the problem. It recommends understanding equipment contents, verifying labels, reviewing service changes, following line-breaking and lockout procedures, and resolving uncertainties before proceeding.
- 201918 Jun
Three hand injuries
This safety flash summarises HSE findings concerning three companies and serious hand injuries involving saws, a planer thicknesser and defective hydraulic cutters. It describes failures in machinery guarding, risk assessment and safe working arrangements, alongside inconsistent lock-off and isolation procedures. One company’s account includes two separate finger-amputation incidents.
- 201913 Jun
Safety Alert 356 - Pipeline Pigs Inadvertently Launched in Close Proximity of Personnel into Gulf Waters
Three pigs were inadvertently ejected near two employees during pipeline pigging on a Gulf of Mexico platform, damaging structures and entering the sea. The alert identifies trapped valve-body pressure as the most likely cause and recommends considering revised hazard analyses, operating procedures, valve inspections, training and near-miss reporting.
- 20194 Jun
Don’t put your finger in the wrong place: Failure to isolate equipment causes serious finger injury
An ROV manipulator repair resulted in the loss of approximately 1 cm of a worker’s left index finger while checking clevis and hydraulic shaft alignment. The flash identifies live hydraulics, unconsulted manuals and inadequate task risk assessment, and recommends hydraulic isolation, lockout/tagout and adherence to technical instructions.
- 201913 May
Near miss: Fire of electrical distribution board during diving operations
A barge lost electrical power during air diving at 18 msw when breaker removal created a short circuit and bus-bar flash fire. The diver was recovered using backup power without injury. The flash identifies failures in isolation, lockout/tagout, work permitting and communication between simultaneous electrical and diving operations.
- 201912 Mar
Near miss: Potential fire – overheating of oil in deep frying pan
A vessel galley near miss involved smoking cooking oil above 200 °C in a deep-frying pan. Both thermostat sensor elements were displaced. The flash describes lockout/tagout, sensor repositioning and thermostat testing, and highlights crew unfamiliarity with the equipment alongside cleaning instructions and recommended checks on other vessels.
- 201928 Jan
Person felt unwell while working in confined space
A worker became dizzy and weak while cleaning a mud tank and was rescued by the tank watchman. The flash identifies deficiencies in permits, atmospheric checks, gas detector use, isolation and rescue arrangements. It highlights missing mud hazard information and checks of lockout kits, detectors and rescue equipment.
- 2018Feb
Electrical PINCs
A platform electrical-system compliance checklist links inspection questions to federal regulatory authorities, API recommended practices and enforcement actions. It covers hazardous-area classification, battery installation, lighting and portable devices, wiring and grounding, explosionproof and pressurised equipment, electrical lockout/tagout procedures and transformer nameplate information.
- 20177 Nov
Lost time injury (LTI): Finger injury during main engine exhaust valve overhaul
An engineer lost his fingertip when compressed air was reopened while he cleaned an exhaust valve seat after overhaul and testing. The flash identifies misunderstood hand signals in a noisy engine room and failure to disconnect the air, with actions addressing communication, risk assessment and familiarisation with lockout/tagout procedures.
- 201718 May
Delaware City Refining Company
CSB safety bulletin examines a flash fire during maintenance preparation at Delaware City Refining Company. Hydrocarbons backflowed through a leaking closed valve while vessels were being emptied. It discusses isolation integrity, informal preparation instructions and management of change, with lessons on more protective isolation and an appendix reviewing other maintenance-related incidents.
- 201713 Feb
Near miss: Unidentified differential pressure led to diver’s umbilical getting trapped
An inshore diving near miss involved an umbilical drawn into a gravity-fed seawater intake and trapped by automated cleaning equipment. A second diver cut the line, enabling both divers to surface uninjured. Findings address undisclosed automation, inadequate isolation and risk review, with corrective actions covering lockout verification and dive-tender repositioning.
- 20166 Dec
First aid injury: Electric shock
An ROV supervisor contacted a conductor in the wrong transformer cabinet during fault finding, suffering an electric shock and hand burn. The alternate system received 40V DC despite its breakers being off and potentially held high-voltage capacitive energy. Lessons address isolation, cabinet access, system familiarisation and testing before touch.
- 201618 Oct
Serious finger injury during valve installation
An engineer lost the tip of his left middle finger while testing a replacement pneumatic valve for a vessel fuel system. He applied compressed air with an air-gun while manipulating the valve-flap with his fingers. The flash discusses inadequate planning, shortcuts, risk assessment and failures to apply permit and isolation procedures.
- 201627 Jan
Lost time injury (LTI): Stored pressure release – Crewman lost an eye
A crewman lost his left eye while installing an emitter protection tube in an offshore vessel’s freshwater UV disinfection unit. Water pressure expelled the glass tube after apparent inadvertent valve opening. The flash identifies valve design, restricted ergonomics, incomplete isolation, absent work authorisation and failure to wear required safety glasses.
- 20152 Oct
Electrical shock – Failure of isolations and barriers
A crew member received an electrical shock while stripping insulation during replacement motor work. The isolation omitted a space-heater supply in the test position, and a generic motor drawing had been used. The flash stresses equipment-specific drawings in permit-to-work and lockout/tagout procedures when determining isolation.
- 201528 Aug
Finger/hand injuries
Two incidents concern a severed finger during blowout preventer ram unlocking and fractured fingers during lifting of a pup joint bundle. The flash identifies absent isolation and communication in the first case, and load proximity and handling deficiencies in the second. Corrective measures include guarding, job hazard analysis and stop-work interventions.
- 201225 Jun
Near-miss: Live electrical cable
During contractor equipment demobilisation aboard a vessel, removal of lockout/tagout re-energised a disconnected cable at 440 volts. Its ends touched the chassis and arced near an employee’s hand; nobody was injured. The flash identifies communication, permit, isolation verification, multiple-key lockout, breaker labelling and electrical drawing deficiencies.
- 201225 Jun
Two recent incidents involving injuries
Two vessel incidents involved a crewman dropping an electric angle grinder after losing balance at the top of a ladder, cutting above his knee, and an engineer suffering finger lacerations when a compressor started. The compressor had not been isolated or tagged out because the task was considered a ‘two minute job’.
- 2011Sep
Hazards from Abandoned Equipment — Process Safety Beacon, September 2011
Four examples illustrate hazards from abandoned equipment, including propane leakage, product contamination, an electrical ground fault and a toxic cloud from residual phosphorus trichloride. The bulletin recommends management of change, isolation, lockout and tagout, removal of abandoned assets, management awareness and periodic inspection of equipment remaining out of service.
- 201119 Jul
Near-miss: Personnel almost caught between crane house and scaffold pipe
An NDT inspector narrowly avoided being trapped between a slewing crane housing and scaffolding after inspecting welds. A deck supervisor intervened to stop the crane. The flash identifies failures in operator notification, guarding, lockout and tagout, initial instruction and toolbox communication, alongside an ineffective last-minute risk assessment.
- 201122 Feb
Safety Alert 292 - Synthetic Base Mud (SBM) Inadvertently Discharged Overboard
During mud-pit cleaning, 98 bbl of synthetic base mud was inadvertently discharged into Gulf waters. The alert identifies outdated schematics, mislabelled valves, crew unawareness of line alignment, inadequate supervisory checks and a generic job safety analysis. Recommendations address piping verification, task-specific responsibilities and consideration of lockout arrangements and operational training.
- 201110 Jan
Safety Alert 291 - Cutting into Process Piping Results in Pollution Event
A contractor replacing corroded piping on a production platform cut a hydrocarbon-containing dump line with an electric band saw, releasing liquid onto the worker and into Gulf waters. The alert identifies failures in hazard recognition and process isolation, alongside absent rescue arrangements for elevated work over water. No injury or fire occurred.
- 201027 Sep
Safety Alert 289 - Failure to Follow Lock-Out/Tag-Out Procedures Results in Gas Release
During turbine compressor overhaul on a production platform, pressure from a shared suction system displaced a plumber’s plug, releasing gas and triggering platform shut-in. The alert identifies conflicting isolation instructions and inadequate operator oversight, recommending identification of shared piping hazards, positive isolation and familiarity with lockout and tagout policy.
- 201024 Sep
Failure to Follow Lockout Procedures Results in a Near-Miss
This alert describes a near-miss involving a mud pump activated by the driller while rig personnel cleaned its suction screen. It identifies failure to follow lockout procedures. No injuries occurred, as personnel were not working on the piston rods, bull gears or similar components.
- 20108 Apr
Crewman received 440V electric shock
An electrician received a 440V shock while reconnecting power to temporary living quarters during refit work at a repair yard. The supply had not been isolated, and the cable had a live male end. The company changed socket arrangements and reinforced lockout and tagout procedures.
- 2010Mar
The safe isolation of plant and equipment
HSE guidance explains how to select, install, prove and maintain process isolations for intrusive work, then reinstate plant safely. It combines baseline selection with risk assessment, valve and pipework design, work authorisation and isolation security. Appendices address specialist methods, pipelines, purging and instrument isolation, supported by incident examples.
- 20092 Jun
Electric shock near-miss
An ROV technician received an electric shock while rerouting a tether, without injury. Energising the tether management system produced induced voltage in isolated conductors, while two earthing clips had become dislodged. The flash examines insecure earthing connections and recommends design improvements, high-voltage training and warning signage.
- 200911 Mar
Safety Alert 277 - Mechanical Motion Equipment Injuries
A mechanic injured his hand when a cleaning rag was drawn into a running generator fan whose shroud did not fully conceal the blades. The alert explains hazardous mechanical motions, hazard analysis and safeguarding techniques, including guards, protective devices, awareness measures, housekeeping, lockout/tagout and supervised training.
- 200826 Apr
Mud Pump Maintenance Results in Serious Injury
A derrickman suffered a serious lower-leg injury when a mud pump was powered up during swab maintenance. A breaker lock had been fitted, but no other lockout/tagout requirements were performed. The motorman removed the lock and authorised restart while the derrickman was still working on the pump.
- 200630 Apr
Isolation of fuel tanks
A vessel in dry dock accidentally received fuel in a tank prepared for hot work, spilling around seven cubic metres of marine diesel onto the dock. The flash examines ineffective isolation despite permits and lockout/tagout, and recommends blind flanging, recorded isolation tags and communication of open-tank status.
- 20052 Jul
Suction Tank Confined Space Hazard
Two employees entered a rig mud pump suction tank for cleaning after permit completion and review of a lock-out JSA. An overlooked pressure-relief discharge connection led into the compartment from an unisolated pump whose bleed-off line remained unopened. A supervisor recognised the danger and removed the employees before an incident occurred.
- 200531 May
Safety Alert 231 - Human Engineering Factors Result in Increasing Number of Riser Disconnects
This alert reviews accidental and emergency riser disconnects in deepwater operations, highlighting human error, hydraulic connection mistakes and station-keeping failures. It recommends reviewing existing requirements for deliberate sequential disconnection, protected controls and documented subsea function testing. An accompanying table summarises eleven events involving drilling and production risers.
- 20054 Apr
Safety Alert 229 - Inadequate Job Planning Results in Atmospheric Release of Gas
This alert describes gas escaping during platform valve maintenance after production personnel re-pressurised the system to move condensate. Gas migrated back from the sales pipeline, prompting personnel evacuation. MMS identified inadequate job planning, communication and isolation, and recommended supervisory instructions, lockout and tagout, and communication of simultaneous operations.
- 20051 Mar
Near-miss: Diver’s umbilical severed by propeller
A diver working on an offshore platform riser surfaced unharmed after a lift boat’s slowly turning propeller drew in and severed the umbilical. The driveshaft securing procedure failed for unknown reasons. Recommendations require a padlocked purpose-built clamp, elevation to expose the propeller and rudder, and joint vessel–dive crew job hazard analysis.
- 20043 Mar
Failure to Follow Lockout Procedure Results in Injury
A motorman suffered an upper-arm fracture and severe bruising when a mud-mixing pump motor became energised during removal work and swung into him. The operating chain was thought to have contacted the pump switch. Work had begun without a permit, Lock/Tag/Try or JSA review.
- 20031 Aug
Electrical safety
This safety flash responds to reports of several electrical safety incidents. It identifies shock, arc burns and electrical fires as hazards of energised equipment, and recommends applicable work permits, stored-energy lockout/tagout and a pre-work job safety assessment or toolbox talk to determine safeguards and protective equipment.
- 198620 Jun
Safety Alert 86 - Fatality
A driller’s helper suffered fatal injuries when a mud-tank agitator activated during cleaning on an offshore drilling platform, entangling him in its paddles. The operator’s stated actions include improved crew communication, electrical de-energisation with lockout and tagging, safety-meeting discussion and inspections to check implementation.
- Undated
UPS Capacitor Failure and Power Loss at Perdido Spar
Investigates a reported fire and power loss at Perdido Spar following UPS capacitor failure. Smoke detection triggered automatic shut-in and personnel mustered; the fire team saw no fire. Electrical troubleshooting identified inverter arcing before lockout and bypass. The report recommends replacing fans and capacitors on similar units.
- Undated
Arc Flash During Vapour Recovery Unit Cable Replacement
An investigation examines an arc flash during vapour recovery unit cable replacement on Pompano platform. A bandsaw cut the wrong, energised cable, causing equipment damage but no injuries or pollution. Findings address incorrect cable identification, missing verification, incomplete task hazard analysis and failures to provide and follow cable demolition procedures.
- Undated
Gas Release During Valve Removal on Production Platform
Investigation of a gas release during valve removal on a production platform. Inadequate isolation allowed pipeline gas to escape through open-ended coalescer piping. The report identifies check-valve malfunction, rushed decisions, deficient procedures, poor communication and fatigue, and recommends lockout and tagout, stop-work processes and coordination of simultaneous operations.
- Undated
Two Subsea Xylene Releases During Marco Polo Operations
BSEE investigates two subsea xylene releases associated with Marco Polo operations in January 2025. The first involved failed seals in an inline logic cap unsuitable for xylene service; the second followed an uncommunicated replacement delay caused by weather. Corrective actions included a suitably rated cap, revised isolation procedures and personnel retraining.
- Undated
Synthetic Oil-Base Mud Spill During Transfer to Sand Traps
An investigation records the release of 91 barrels of synthetic oil-base mud into Gulf waters during transfer to sand traps. Findings identify inadvertent valve opening, an incompletely closed master dump valve, installation and verification deficiencies, and inadequate orientation. Recommendations address valve marking, lockout and explanation of procedures.
- Undated
Thief-Hatch Fire During Welding and Cutting
BSEE investigates a small thief-hatch fire during welding and cutting at South Marsh Island 130 A. Slag ignited venting combustible vapours where fire blankets provided insufficient protection. Findings examine inadequate tank isolation, missing valve lockout and tagout, gas-testing locations and unimplemented venting mitigations. No injuries or facility damage occurred.
- Undated
Gas Release from Shared Suction Piping Following Compressor Removal
An offshore production platform investigation examines a gas release following compressor removal. Rising pressure dislodged a plumber’s plug from shared suction piping, triggering gas detection, platform shut-in and muster. Findings identify unsuitable isolation, inadequate JSA hazard recognition and insufficient oversight of the operator’s lockout and tagout policy.
- Undated
Arc Flash During Cleaning of Energised Motor Control Centre Busbars
An accident investigation examines an arc flash during cleaning of energised motor control centre busbars with aerosol solvent and a steel-bristled brush. Findings identify missing work planning, permits and lockout procedures, alongside inadequate protective equipment. Recommendations address cabinet reinstatement planning, safe work permits and cleaning only with the centre de-energised.
- Undated
Mechanic’s Fingers Injured After Rag Entangled in Generator Cooling Fan
A contract mechanic suffered severe finger injuries when a cleaning rag became entangled in an unguarded generator cooling fan after water-pump replacement. The investigation identifies failure to follow lockout/tagout procedures and inadequate contractor supervision, and requires the operator to ensure accountable supervision and adherence to its safe work practices.
- Undated
BOP Test Stump Fell Overboard During LMRP–BOP Connection Leak Testing
An investigation records a BOP test stump falling overboard during leak testing of the LMRP–BOP connection above the moon pool. Inadvertent activation released the stump. The report identifies unrecognised management-of-change needs and absent lockout/tagout, and records planned procedural changes. No damage or pollution resulted; the stump could not be recovered.
- Undated
Mechanic’s Hand Trapped During Compressor Cooling-Fan Troubleshooting
BSEE investigates a mechanic’s injury while troubleshooting compressor cooling-fan vibration on Eugene Island platform 360-C. His left hand was drawn between a still-moving belt and sheave after shutdown, fracturing two fingers. The investigation identifies failures to apply stop-work authority, job safety analysis and lockout/tagout arrangements for residual energy.
- Undated
Finger Injuries While Clearing Shale from Rotating Shaker Auger
A contract employee injured his fingers after losing balance while clearing shale from a shaker auger and contacting its rotating parts. The investigation identifies absent lockout and supervision, a removed cover and inadequate cleaning instructions in the JSA. It records recommendations on guarding, shutdown, training and task planning.
- Undated
Gas-Pressure Release During Tree-Cap Flange Replacement
Investigation of a gas-pressure release during tree-cap flange replacement on well A-15 at Vermilion 369 Alpha. A contractor sustained eye and facial exposure and required medical evacuation. Findings identify inadequate lockout/tagout, missing written isolation instructions, limited platform-specific operator experience and unsuitable working surfaces affecting body positioning.
- Undated
Worker’s Hand and Arm Trapped During Spinner Hawk Chain Adjustment
Investigation of a drilling injury involving a Spinner Hawk chain adjustment. Unintentional operation of the close lever trapped a worker’s hand and arm. Findings address accepted adjustment practices, missing isolation, inadequate task analysis and unlabelled controls. Recommendations cover training, equipment-specific analysis, control labelling and hydraulic isolation.
- Undated
Condensate Flash Fire During Pipe Welding
An investigation examines a condensate flash fire during pipe welding that burned a contract rigger. A leaking block valve allowed pressure and condensate to accumulate behind a plumber’s plug, which ejected. Findings address inadequate isolation, hazard assessment and lockout/tagout, while noting that production remained online.
- Undated
Synthetic-Base Mud Discharge During Cement-Unit Mixing Equipment Testing
Investigation of a Gulf of Mexico release during cement-unit mixing equipment testing. Open measuring-tank valves allowed synthetic-base mud to mix with drill water discharged overboard. Four barrels of mud contained 2.12 barrels of base oil. The report records valve lockout, job safety analysis and sequential-operation requirements introduced by the cement company.
- Undated
Drilling Mud Discharge Following Loss of Slip Joint Seal Pressure
Investigation of a 223.3-barrel synthetic-based drilling mud discharge into the Gulf of Mexico from West Sirius. A hydraulic supply valve left closed after maintenance deprived the telescopic slip joint seals of pressure. The report discusses startup procedure failures, a failed pressure alarm, valve identification improvements and additional alarm-response requirements.
- Undated
Fingertip Amputations During Air Handling Unit Belt Check
BSEE investigates a drillship engineer’s fingertip amputations while checking an air handling unit belt at Garden Banks Block 259. His hand was drawn between the moving belt and pulley after power was switched off. Findings address absent lockout/tagout, supervision and communication, and failure to follow documented hazard identification.
- Undated
Variable Frequency Device Failure Releases Smoke and Prompts Muster
BSEE investigates a variable frequency device failure at Perdido Spar that released smoke, triggered automatic shut-in and prompted personnel muster. The report attributes the event to a B-phase reactor failure to ground, describes electrical isolation and fire watch, and calls for investigation of the reactor thermal switch’s failure to trip.
- Undated
Electrical Shock During Water Maker Level Sensor Cleaning
An investigation examines an electrical shock sustained while a contractor cleaned water-maker level sensors. The report identifies an electrical malfunction that prevented a breaker from tripping and energised tank water, alongside failure to isolate power. It discusses lockout procedures, manufacturer switch instructions and subsequent employee communications.
- Undated
Synthetic-Base Mud Discharge from Drill Ship into Sea
Investigation of a 368-barrel synthetic-base mud discharge from the Rowan Relentless drill ship into Gulf of Mexico waters. The report identifies poor communication, unverified valve alignment and a half-open splitter valve, alongside inadequate pit monitoring, simultaneous fluid operations and unlocked dump valves. No recommendations to the Agency were made.
- Undated
Gas Release Following Compressor Shutdown on Medusa Spar
BSEE investigated a gas release at Medusa Spar following a compressor shutdown. Backpressure reached an improperly reinstalled blind flange lacking its required gasket; isolation arrangements had not accounted for an automatically opening blowdown valve. Gas detection shut in production, and all 31 personnel safely mustered. No damage or pollution occurred.
- Undated
Flash Fire During Preparation for Flare Scrubber Inspection
An investigation describes a flash fire during preparation to inspect Platform Irene’s flare scrubber vessel. A lead operator sustained minor burns and embedded debris in his hand. Findings identify failures in purging, isolation, lockout and ignition control, alongside permit compliance and communication deficiencies. Follow-up included permit checks and training.
- Undated
Hydrocarbon Spill During Cutting of Unisolated Platform Piping
Investigation of a hydrocarbon spill during replacement of corroded piping on an offshore platform. A worker using an electric band saw cut a line that had not been isolated and cleared of hydrocarbons. No injury occurred. Findings identify deficient task-specific hazard analysis, failure to follow lockout procedures and difficult rescue access.
- Undated
Hydrogen Sulphide Release During Condensate Rerouting
Investigation of a hydrogen sulphide release on Hidalgo platform during condensate rerouting. Opening the wrong valve, combined with a check valve lacking a positive seal, allowed condensate into deck drains. Five workers received medical care and were evacuated. Corrective measures included locking the valve, documenting procedures and planned pipework alterations.
- Undated
Pump Manifold Expelled During Disassembly While Cleaning Mud Tank
Two workers cleaning a mud tank on Hercules 204 were injured when residual discharge pressure expelled a diaphragm pump manifold, mud and debris during disassembly. The investigation identified absent job safety analysis, lockout/tagout practices, disassembly procedures and a discharge bleed valve. Both workers received medical treatment; Pisces subsequently introduced a temporary-pump safe work practice.
- Undated
Flash Fire During Plug Removal from High-Pressure Vent Line
An investigation examines a flash fire that severely burnt a rigger’s arms during removal of a plumber’s plug from a high-pressure vent line. Premature spool installation allowed gas to accumulate. Findings address ineffective valve isolation, failure to verify pressure and construction miscommunication; welding ground clamps were identified as a possible ignition source.
- Undated
Casing Leak Released Oil and Gas into Sea
BSEE investigates a casing leak at South Pass 28 13(V) that released oil and gas into Gulf of Mexico waters. The report traces unsuccessful well-killing attempts, bridge-plug isolation and welded repair. It identifies inadequate preventive maintenance, corrosion and erosion as probable causes, alongside rough seas and shallow water as contributing conditions.
- Undated
09-7-2022 1600 G24878 SM 192 A Crane - Incident > $25,000
BSEE investigates crane boom damage discovered at South Marsh Island 192 A on 7 September 2022. The report attributes damage to an incorrectly positioned high-angle kick-out switch allowing boom-stop contact. It examines unperformed pre-use function tests, unrecognised damage, isolation and subsequent crane derating; the actual damage date remained uncertain.