Control
Simultaneous Operations Coordination
Coordination of interacting operations and their combined hazards.
Documents
- 202615 Apr
UK HSE: electrician seriously injured on onshore wind farm
An electrician sustained life-changing injuries during substation maintenance at an onshore wind farm. The investigation identified departure from a prepared switching programme and inadequate checking and change approval processes. The flash highlights safe work systems, management of change, coordination of parallel tasks, electrical-work review and supervision.
- 202631 Mar
Source control planning and procedures information paper
This information paper sets out regulatory expectations for offshore loss-of-well-control preparedness across environment plans, well operations management plans and safety cases. It covers capping-stack selection and deployment, relief-well design and dynamic kill analysis, plume modelling, subsea dispersant supply, water-column monitoring, response-time modelling, coordinated operations and readiness exercises.
- 202624 Mar
Dropped object – strop parted over sharp edge
During a yard stay, an 8.6-ton crane cylinder fell through a vessel’s deck after sharp edges cut a soft sling despite firehose protection. No personnel were injured, but painters were nearby. The flash discusses hard rigging, conditional sling-capacity reduction, risk reassessment and permits addressing conflicting work.
- 202623 Feb
PEMEX Deer Park Chemical Release
CSB investigation of a fatal hydrogen sulphide release during refinery maintenance in Deer Park, Texas. Workers opened the wrong flange on active piping. The report examines equipment identification, permit scope and hold points, interacting maintenance operations, contractor reassignment and operational discipline, recommending clearer marking and work authorisation arrangements.
- 202518 Dec
BSEE: Anchor-handling causes damage to subsea equipment and triggers gas release
An anchor wire snagged a subsea well during recovery by a dive support vessel, subsequently detaching an annulus valve and releasing gas. The flash summarises BSEE findings on inadequate planning, coordination and emergency preparation, with recommendations for consideration covering readiness checks, change management, communication and current-aware anchor-handling plans.
- 202516 Oct
Fatal injury to a recreational diver following contact with the motor vessel Karin operating as a recreational dive support vessel
Investigates a recreational diver’s fatal propeller strike during a drift decompression stop in Scapa Flow. Examines Karin’s obstructed forward visibility, ineffective lookout, marker-buoy attachment, vessel coordination and absent documented safety arrangements. Recommendations address harbour oversight, while the annexed bulletin discusses safe vessel separation and hand-held marker-buoy lines.
- 2025Oct
Refinery Cooling Tower Explosion and Fire — Process Safety Beacon, October 2025
A refinery cooling tower incident in India illustrates how hydrocarbons leaking from a heat exchanger can accumulate in cooling water pipework and escape during commissioning. Ignition was likely associated with nearby hot work. The bulletin discusses exchanger vulnerability, start-up hazards and notifying nearby workers so they can suspend work.
- 202530 Sep
BSEE Safety Alert 508 -Review anchor-handling plans now Incident damages subsea equipment triggers gas release
A diver support vessel recovering bow anchors snagged a subsea well with an anchor wire. Attempts to free it detached the annulus valve, releasing gas. The alert identifies deficient planning, contractor coordination and emergency readiness, and recommends that operators and contractors consider stronger pre-mobilisation checks, SIMOPS arrangements and anchor-handling plans.
- 202511 Aug
BSEE Safety Alert 505 - BSEE Risk-Based Inspections Reveal Increase in Slip-Trip-Fall Hazards on Offshore Facilities Inspections
BSEE reports findings from a Performance-Based Risk Inspection of 19 offshore assets following an increase in slip, trip and fall injuries. Findings address training gaps, obstructed walkways, sharp edges, simultaneous operations, safety boots and faded markings. Recommendations invite operators and contractors, where appropriate, to consider improved hazard checks, housekeeping, training and footwear maintenance.
- 202516 Apr
BSEE: Crane safety awareness during offshore helideck operations
An offshore helicopter landing nearly ended in collision when a crane operator raised the boom as the aircraft was 10 feet from touchdown. The pilots performed a successful go-around. Drawing on BSEE findings, the flash highlights procedural enforcement, communication and coordination, with recommendations also applicable to vessel approaches and simultaneous operations.
- 2025
SAC Underwater Noise Regulators Working Group Progress Report 2025
Annual review of regulators’ management of impulsive underwater noise in harbour porpoise protected areas during 2025. It describes the shared noise tracker, pre-season predictions, development coordination and twice-weekly scheduling calls. Southern North Sea summer disturbance remained within thresholds; registry improvements, deterrent-range revisions and international initiatives are also covered.
- 20245 Nov
BSEE Safety Alert 491 - Vigilance Required in Offshore Helideck Operations
A helicopter approaching an offshore helideck avoided collision by going around after a crane boom was raised near the landing area. The alert identifies communication and procedural enforcement shortcomings. BSEE recommends operators and contractors consider crane-movement suspension, coordinated communications, helideck checks, training and routine audits.
- 202424 Oct
Dropped sheave and clump weight
During wind turbine monopile installation, a clump weight was hoisted into a sheave, breaking it and dropping both components onto the deck. No injuries occurred, but equipment damage and a hydraulic oil spill resulted. The flash highlights simultaneous winch operation, inadequate observation, absent automatic stops and lessons on lift oversight and stopping unsafe work.
- 202425 Sep
UK HSE: fall from height injury at container port
A worker undertaking routine maintenance at a container port fell over 10 metres through an opening in a straddle carrier cab, sustaining serious injuries. Contractors had removed the glass floor for replacement. The flash highlights failures in simultaneous-work coordination, risk assessment and implementation of the employer’s working-at-height permit policy.
- 202427 Jun
Safety warning issued following contact between a diving support boat and a recreational diver with loss of 1 life
This bulletin examines a fatal recreational diving accident in Scapa Flow, almost certainly involving Karin’s rotating propeller. It highlights an unseen delayed surface marker buoy during drift decompression, dedicated lookouts, safe vessel standoff and coordination between boats. Divers should hold buoy lines rather than attach them to themselves.
- 202427 Mar
Loss of heading control on an FPU during diving operations
A floating production unit lost heading control during diving operations when a steering pump failed to start automatically during greasing. Only one thruster was available. Divers were recovered safely. The flash examines maintenance coordination, work permits, risk assessment and communication, and calls for changes to the company SIMOPS matrix.
- 202419 Mar
Person pulled to deck by fall arrest harness
A swinging crane whip line caught a worker’s fall-arrest wire during moonpool preparations, pulling them to the deck; no injuries were reported at the time. The flash identifies communication, planning and supervision shortcomings during parallel activities, and recommends clearer communication, conditional tagline use and careful harness connection-point selection.
- 202414 Feb
BSEE Safety Alert 481 - Hazardous Helideck Conditions Results in Near Miss Incident
An offshore helideck near miss involved unsecured safety skirting moving in helicopter rotor downwash after landing clearance. BSEE recommends that operators and contractors consider checks before clearance, coordination of simultaneous operations, facility-specific procedures and briefings, alongside notifications and visible markings for out-of-service helidecks.
- 202412 Feb
MSF: Two dropped object incidents
Two vessel incidents involved a metal wedge falling 13 m during gangway pin removal and a lightning rod falling 26 m onto deck. The flash examines unsecured items, access to drop zones and rod fittings, describing tethering modifications, improved barriering guidance and planned maintenance checks.
- 202416 Jan
BSEE Safety Alert 479 - Lack of Adherence to Helideck Safety Procedures Results in Series of Near Miss Incidents
BSEE reviews six helideck near misses involving gas venting during approach, loose debris, grease, unsafe approach to a running helicopter, crane interference and raised handrails. It recommends that operators and contractors consider personnel instruction, facility-specific procedures, operational planning and pre-arrival briefings to strengthen helideck safety.
- 202313 Nov
Positive: Master stopped unsafe fuel transfer whilst vessel alongside rig
A supply vessel halted fuel transfer after its watch officer spotted welding on an adjacent semi-submersible rig. The flash highlights prompt bridge intervention, reporting and positive recognition by rig management. It identifies missing communication about hot work despite mandatory confirmation of simultaneous operations through the Safety Zone checklist.
- 202312 Sep
Fatality due to fire incident and fall from height
A rope access technician undertaking pipelay tower maintenance suffered a fatal fall from approximately 8.5 m after welding particles ignited solvent and fire melted the body harness. The flash examines independently authorised, conflicting work and highlights coordinated permits, shared planning, whole-operation supervision and effective stop-work authority.
- 202315 Aug
Caught between: Unplanned movement of equipment leads to severe injuries
A mechanic suffered severe injuries when moving hydraulic hoses tipped a three-tonne hose saddle towards a container door, trapping him. The flash examines instability, absent securing and shortcomings in change management and work coordination during maintenance. Actions address equipment stability, sea-fastening, work authorisation and toolbox participation.
- 202315 Jun
Wacker Polysilicon Chemical Release
This investigation examines a hydrogen chloride release during heat-exchanger maintenance at Wacker Polysilicon. Excessive bolt torque fractured a graphite nozzle; three workers fell while escaping, with one fatality. The report analyses maintenance instructions, hazardous-energy control, simultaneous insulation work and restricted egress, recommending clearer procedures, coordinated operations and additional escape routes.
- 20221 Nov
Failure to plan properly: electrician sustains serious burns (UK HSE)
An electrician suffered serious burns at a supermarket warehouse when his metal spanner contacted a live busbar, causing an electrical explosion. Generator connection work alongside high-voltage maintenance lacked adequate planning and contractor coordination. The flash highlights failures to stop the circuit supply and appoint a competent person to organise the work.
- 202228 Feb
MSF: LTI – Fall from Height (control of work during SIMOPS)
A crew member fell 3 m through removed gantry grating during vessel superstructure maintenance, in an incident classified as a lost-time injury. The flash identifies ineffective work-control systems, poor situational awareness and communication, and absent barriers or signage. Actions address simultaneous operations planning, pre-task risk assessment and toolbox talks.
- 202225 Feb
Jacking Up Lift Boat During Crane Operations
During well abandonment, a lift boat was raised with crane slings still connected to a wellhead. Suspected snagging on hanger pins preceded sling failure and injury to an operator. BSEE recommends considering interface disconnection, attentive crane operation, elevation-adjustment procedures and job safety analysis addressing interconnected equipment.
- 202210 Feb
Equipment on quay damaged when vessel started listing
A quayside pad-eye inspection using a mobile elevated work platform resulted in basket handrail damage when crane movement caused the vessel to list and its pipelay tower to strike the basket. The flash identifies missing work authorisation, inadequate simultaneous-operations assessment and operator training, and recommends coordinated planning and practised rescue arrangements.
- 20219 Dec
Failure of 64mm polyester rope in subsea mooring operations
A 64mm polyester rope parted while subsea equipment was being lowered, following overload from unsynchronised crane and deployment-winch movements. Nobody was injured, but equipment was damaged. The flash examines missed operator concerns, simultaneous operations and unused stop-work authority, and describes tension indication, improved coordination and retraining in existing procedures.
- 202124 Sep
Evergreen Packaging Paper Mill - Fire During Hot Work
Investigation of a fatal fire during paper-mill tower maintenance in Canton, North Carolina. A heat gun fell into flammable resin, and fire spread between connected bleaching towers, killing two workers. The report examines hot-work recognition, confined-space permits, contractor coordination, combustible fibreglass construction and emergency response, with recommendations for procedures and training.
- 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.
- 20218 Apr
SIMOPS – Smoke from hot work task enters confined space
During sewage-tank cleaning aboard a vessel in dry dock, a ventilation fan drew smoke from nearby oxy-propane cutting into the confined space. Workers evacuated without harm. The flash examines gas-detector placement, overdue calibration and missing bump tests, and identifies improvements to simultaneous operations planning and fume extraction.
- 20212 Feb
LTI: Stored energy – rigger injured leg working on quayside
A rigger suffered a significant lower-left-leg injury during night-time quayside lifting and vessel demobilisation. Identified factors included an accepted risky forklift method for moving slings, blocked walkways, restricted driver visibility, removed high-visibility clothing, reduced lighting, absent port induction and poorly controlled simultaneous activities. The flash encourages stopping work when required.
- 202028 Sep
Unsafe lifting operations
Two vessel lifting interventions concern a winch frame beneath scaffolding being dismantled and a metal structure offered for loading without available lifting certificates. The flash discusses conflicting activities, an unsafe partial-lifting and rolling method, weather-related haste, lift planning, equipment colour coding and checks before and after work.
- 20196 Dec
Welder at work injured during close SIMOPS
A welder attaching lashing eyes to a deck sustained a slight neck injury from a wire while nearby crew secured reels. The flash identifies poorly managed simultaneous operations, inadequate supervision and preparation, and limited awareness of surroundings. Lessons emphasise understood toolbox talks, pre-task preparation and monitoring during hot work.
- 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.
- 2019
Structural response to vessel impact
Guidance explains HSE expectations for assessing offshore installations’ structural response to attendant vessel collisions. It covers structural analysis, damage escalation, safety-case evidence and design criteria for new and existing installations. Simplified techniques and finite element analysis support assessment of impact capacity, vessel displacement and tolerable velocity, with periodic reviews and marine controls where required.
- 201823 Aug
Serious injury caused by energy isolation failure
A yard worker sustained a serious forearm injury when another worker lowered a hydraulic pipe stand during debris cleaning. The flash identifies absent energy isolation routines, inadequately assessed simultaneous operations and equipment modification, and insufficient task planning. Lessons address risk assessment, coordinated permit and isolation controls, and management of change.
- 201810 May
Safety Alert 332 - Crane Hazards Identified by BSEE in Risk Based Inspections
BSEE reports findings from targeted crane risk inspections in the Gulf of Mexico following analysis of incident and compliance data. Deficiencies concern inspection effectiveness, maintenance tracking, load indicators, tag lines and competence assurance. Recommendations address lifting equipment maintenance, hand signals, personnel transfer procedures, safety communication and coordination of simultaneous operations.
- 20182 Mar
Worker fatally injured in falling from a scissor-lift platform which collided with another vehicle
A worker suffered fatal injuries after an LGV struck his scissor-lift platform, ejecting him onto a roadway from a height of 1.5 metres. The flash reports HSE findings on inadequate planning of work at height and the need to segregate it spatially or temporally from workplace transport.
- 201721 Sep
Property damage: Platform supply vessel collided with legs of jack-up rig
A platform supply vessel struck a jack-up rig leg after its starboard engine and thrusters tripped following water transfer, while the hose remained connected. The flash identifies fuel-oil pump seal failure and weather-side working contrary to procedures, and highlights simultaneous-operations risk assessment and planned maintenance.
- 201711 Aug
Power loss within dive control
A vessel’s dive-control electronics lost power during ROV recovery on a shared power bus. Low supply voltage activated the UPS internal bypass, after which circuit breakers tripped. The dive was aborted without injury. Actions included keeping the bus tie breaker open, disabling internal bypass and introducing daily UPS health checks.
- 201612 Oct
Medical treatment: Person fell down unprotected hatch
A shore-side foreman stepped into an open manhole in a supply vessel’s safe haven area. He caught himself, preventing a free fall of 5 m, but sustained shin and forearm injuries. The flash identifies missing barriers and poorly coordinated simultaneous activities, with corrective actions involving gratings and toolbox talks.
- 201612 Oct
Near-miss: Open hatches left without barriers
During contractor tank cleaning aboard a supply vessel, ten hatches remained open for ventilation without individual barriers, despite taped area barricading and a standby person. The flash describes an unchallenged fall hazard and subsequent work stoppage, risk assessment review, clarification of simultaneous-operation responsibilities, and ordering of barriers and vented grating.
- 201627 Jan
Crew transfer vessel (CTV) personnel transfers
Two offshore wind crew-transfer incidents illustrate hazards from fall-arrest attachment during vessel movement and thruster wash near a dynamically positioned construction vessel. The flash describes a rogue wave during a dark winter transfer, suspension of transfers pending improved conditions, and revised vessel separation and work sequencing arrangements.
- 20157 Dec
Fatality during loading operations
A crew member was fatally trapped between cargo items when heavy seas shifted unsecured loads aboard a vessel after back-loading from a drilling rig. The flash examines open-stern vessel suitability, released tugger-winch tension and gaps in coordination and risk assessment, and records reviews of weather guidelines, cargo procedures and lashing plans.
- 20153 Dec
Crewman falls down open hatchway during simultaneous operations
A crewman sustained a minor ankle injury after stepping into an open engine hatch while sanding a crew transfer vessel in port. Concurrent engine-bay maintenance created an interacting hazard. The flash identifies poor situational awareness and recommends better work coordination, toolbox talks, agreed work plans and risk assessment where new or unknown risks are suspected.
- 2015Feb
Who are all these people? — Process Safety Beacon, February 2015
This bulletin uses three serious process incidents to discuss unnecessary personnel near hazardous operations. It explains how crowding can distract operators and increase exposure during startup, shutdown and abnormal conditions. Recommendations address access arrangements in operating procedures, emergency instructions for non-essential personnel and consideration of postponing other tasks.
- 2011Mar
OCE25 - Well servicing – chemical injection
This offshore COSHH sheet addresses chemical injection during well servicing and coiled tubing operations. It describes chemical exposure and nitrogen hazards, with guidance on planning, protective equipment, line testing, exposure monitoring and dermatitis surveillance. It also covers spill handling, waste disposal, decontamination, training and supervision.
- 200923 Oct
Trapped diver umbilical incident resulting in diver fatality
A surface-supplied diver died after his umbilical became fouled on the seabed, with barge movement thought to have interrupted his gas supply. Wet-bell recovery dragged him out twice before the umbilical was freed. Company actions addressed barge movements, in-water tending, emergency briefings, debris surveys and pre-dive communication checks.
- 200917 Aug
Lift bag lost when rigging parted
A pipeline buoyancy operation lost a lift bag after a strip-out wire cut its webbing strops. The inversion line also pulled handling attachment points from the bag’s crown. The flash highlights task coordination, clearer work communication and purpose-built, labelled inversion attachment points for future equipment procurement.
- 20083 Dec
Fatality: struck down by falling object during lifting operation
A shipyard worker was fatally struck by an angle plate during a ballast-tank lift. The plate or its webbing rigging snagged, allowing it to slip free of the choked sling. The flash identifies unsafe rigging, disregarded stop-work instructions, poor simultaneous-operations coordination and inadequate control of personnel beneath the load.
- 20081 Apr
Movement of vessel during crane operations caused near-miss
Two personnel working on vessel antennae used a man-riding basket suspended from a shore-side crane. Movement of the onboard crane caused the vessel to heel and the worksite to move away from the basket. No injuries occurred. The flash highlights communication and coordination between interacting operations.
- 20087 Jan
Management of simultaneous operations during demobilisation
During barge demobilisation in port, a lifted object displaced an unsecured steel beam, severely injuring a crew member disconnecting cables below. Site layout prevented the lifting team from seeing the worker. The flash reports recommendations for demobilisation procedures covering communication, planning, risk assessment, workforce involvement and management of change.
- 20061 Mar
Safety Alert 238 - Floorhand Crushed During a Through-Rotary Man-Riding Operation
A floorhand suffered a serious crushing injury when a BOP stack shifted during through-rotary man-riding work while a derrickman separately loosened winch connections. The alert recommends procedure review, signed permits and coordinated JSA meetings, and suggests considering lifting from the Texas deck and halting secondary operations.
- 200614 Feb
Safety Alert 237 - Post-Hurricane Construction Fatality and Other Incidents
Following fatalities, injuries, falls and fires during post-hurricane construction repairs, this alert recommends closer contractor oversight and familiarisation with emergency arrangements. It addresses protective equipment, hot-work permits, barricades and job safety analyses, emphasising interactions with concurrent oil and gas operations and communication across crew and shift changes.
- 20052 Jul
Safe Helicopter Operations
An offshore crew-change alert describes helicopter boarding interrupted by a crane lift from an alongside supply boat. After an uneventful return flight, the pilot found ten passengers rather than the eight manifested. Subsequent manifest checks and weighing established that the aircraft had exceeded its maximum allowable weight by approximately 308 kg.
- 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.
- 200514 Jan
Safety Alert 225 - Fatality on Rig Caused by Snagged Barricade
A rig spotter sustained fatal injuries when a barricade, snagged by an unshimmed shackle during air-hoist lifting of a welding crew, fell after disengaging. The alert recommends pre-use inspection of lifting assemblies, manufacturer-specified pad-eye shimming and detailed job safety analysis of simultaneous operations before planned man-riding.
- 2005
Guidance on permit-to-work systems - A guide for the petroleum, chemical and allied industries
Explains how permit-to-work systems support hazardous work through defined responsibilities, task risk assessment, competence assurance and coordination of interacting activities. Covers permit design, electronic systems, suspension, handover, retention and auditing. Incident examples illustrate failures, while separate checklists support system assessment and daily permit monitoring.
- 20041 Oct
Pipe handling frame incident during diving operation
A diver contacted a pipe handling frame that had settled partly on a pipeline and the seabed during barge crane operations and a shift change. No injury or pipeline damage was reported. The flash discusses intermittent transponder signals, communication failures and the supervisor’s failure to verify the frame’s position before deploying the diver.
- 20002 May
Safety Alert 188 - Fire with Fatality and Injury
A safety alert describes a fatal condensate fire during cutting of a platform drain line with an electric bandsaw, with another employee injured while assisting. It identifies valve opening, continued cutting and procedural and communication shortcomings, and recommends coordinated work assignments, written procedures, job safety analysis, isolation and contractor oversight.
- 19982 Apr
Safety Alert 13 - Crane Accident
A crane boom failed while transferring a bin from a platform to a boat, narrowly missing two crew members and releasing oil into the ocean. The alert explains dynamic load ratings and reiterates requirements for qualified operators, protected slings, personnel clearance and separation of crane work from helicopter movements.
- 19943 Mar
Safety Alert 11 - Crane/helicopter Operations
An alert describes a crane boom swinging in line with a helideck while a helicopter idled before take-off on a Pacific offshore platform. It reiterates crane shutdown, boom securing and operators leaving cabs, recommends arrival announcements, and attaches guidance on pilot–operator coordination, crane visibility and warning indicators.
- 198621 Feb
Safety Alert 146 - Fire During Production Equipment Dismantling Operations
An alert describes a production-platform fire during concurrent welding and equipment dismantling. With the platform shut in, the inactive containment system overflowed back through a drain line, allowing welding sparks to ignite condensate in a drip pan. Planned measures include draining and flushing before shutdown and heightened fire-watch vigilance.
- 198518 Jun
Safety Alert 140 - Uncontrolled Well Flow and Pollution During Workover Operations
During reperforating, leaking casing hanger anchor screws were removed without securing the well, leading to uncontrolled flow and approximately 50 barrels of pollution. The platform was evacuated. The alert reiterates requirements for qualified, certified repair personnel, separation from downhole operations and management approval of procedures for repairs to unsecured wells.
- 198315 Dec
Safety Alert 122 - Injury Due to Failure to Coordinate Activities
A worker suspended by an air tugger for painting preparation was pulled into the finger board when another worker activated the tugger for drill pipe handling, unaware it was in use. The alert describes a planned removable control sign and recommends surveying the work area and coordinating operations.
- 198128 Jul
Safety Alert 105 - Welding Accident
Wind carried welding slag from an upper deck into an open stock-tank connection during platform modification, causing an explosion and small fire. The tank and overhead electrical cables were damaged, without personnel injury. The operator emphasised coordination of concurrent work, supervisory control and the fire watch’s sole duty.
- 197820 Sep
Safety Alert 75 - Helicopter Crashes: 17 Fatalities
A helicopter lost lateral control during landing and its main rotor struck a crane cable before the aircraft fell from the platform into water, killing 17 people. The alert describes wind conditions and landing obstructions, and sets out crane positioning and restrictions on crane activity during helicopter operations.
- 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
Drill-Pipe Joint Struck Floorhand During Hoisting and Lowering
Investigation of a floorhand injury during simultaneous drill-pipe hoisting and lowering. A pipe joint became wedged, bowed and struck the worker, who fell against a gate. Findings identify air-tugger reeving design and an interrupted operating rhythm, with possible fatigue or rushing before shift change. No regional recommendations were made.
- Undated
Platform Fires During Welding and Cutting Above Open Grating
Investigation of two platform fires on 10 and 11 February 2007 during welding and cutting above open grating. Falling slag ignited rags and rope, then polyflow tubing. Findings identify insufficient insulation, concurrent production, hot work near active lines, absent production supervision and missing production involvement in permits and job safety analysis.
- 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
Lever Hoist Broke and Dropped Part During Crane Boom Raising
An investigation examines a crane incident on the Nansen Spar involving lever hoists connecting scaffolding to the crane boom. Raising the boom broke a hoist, dropping part approximately 30 feet. Findings address communication, simultaneous operations and inspection arrangements; operator corrective actions cover anchor-point approval and crane inspections.
- 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
Flash Fire During Coiled Tubing Operations
Investigation of a flash fire during coiled tubing operations beside a producing platform. Gas venting through an open gas-buster clean-out valve migrated to a diesel pump engine and ignited following a backfire, burning the operator. Findings address missing fluid returns, inadequate hazard analysis, delayed simultaneous-operations planning and obstructed emergency egress.
- Undated
Shifting Pipe Trapped Contractor’s Leg During Platform Decommissioning
BSEE investigates a contractor’s fractured femur during platform decommissioning at Eugene Island 259 C. Cutting an 8-inch pipe caused it to shift and trap his leg. The report identifies inadequate crew-location communication and job safety analysis of stored-energy movement, alongside restricted positioning while wearing a harness.
- Undated
Safety Alert 32 - Exxon Company, U.S.A. Platform Harmoney Santa Ynez Unit
An award citation recognises Exxon’s drilling and production performance on Platform Harmony during 1997. It records inspections without detected noncompliance and accident-free operations, praising regulatory knowledge and communication between drilling and production personnel during simultaneous operations. The citation also commends attention to personnel safety and environmental protection.
- Undated
Safety warning after accidental release of vinyl chloride monomer from gas carrier
This MAIB bulletin describes a vinyl chloride monomer release during cargo sampling aboard Coral Acropora at Runcorn. Inadvertent valve opening transferred cargo into a full tank, raising pressure and releasing cargo through the mast riser. Recommendations address pump supervision, concurrent operations, valve segregation, system double-checking and safety-feature overrides.
- Undated
Statoil - Statfjord C - Investigation of hydrocarbon leak
Investigation of a stabilised-oil release on Statfjord C during inter-platform transfer and loading-pump isolation. It examines drainage restrictions, fire-seal defects, missing tank-level alarms and inadequate isolation and concurrent-work arrangements. Oil reached the installation and sea; disturbed evidence and unverified valve conditions limited certainty about contributory causes.
- Undated
Transocean Offshore - Transocean Barents - Investigation into an incident involving personal injury
Investigation of a derrick inspection injury on Transocean Barents during drillstring running. A descending top-drive yoke struck and squeezed a worker against a platform railing. Findings address inadequate platform protection, conflicting access procedures, unclear restricted zones and deficient coordination and risk assessment of simultaneous work.
- Undated
Union Carbide Corp. Nitrogen Asphyxiation Incident — Final Investigation Report
Investigates nitrogen asphyxiation during maintenance at Union Carbide’s Hahnville plant, which killed one worker and seriously injured a contractor. A temporary plastic enclosure trapped nitrogen venting from open process pipework during black-light inspection. The report examines inadequate enclosure procedures, hazard warnings and evaluation of interacting maintenance activities.