Equipment
Operator Displays and Control Interfaces
Operator interfaces and displays substantively examined.
Newest 100 Documents
All 251 in search- 2026Sep
Shell Polymers Furnace Explosion and Fire — Furnace Explosion and Fire at Shell Polymers
Investigates the June 2025 furnace explosion and fire at Shell Polymers Monaca following coke-trap cleaning. Inadvertent opening of isolation valves allowed cracked gas to enter the firebox and ignite. The report examines reliance on administrative safeguards, safety instrumented system bypasses, alarm suppression and confusing valve interfaces, recommending engineered protection and improved interface design.
- 20254 Dec
BSEE Safety Alert - 510 - Blackout and Weather-Driven EDS Incidents Underscore the Need for Stronger Operational Discipline
This alert examines two emergency disconnects on a dynamically positioned drillship: a blackout during damper maintenance involving the wrong control panel, and loss of position during severe weather. Both resulted in pollution. Recommendations invite operators to consider clearer controls, competence verification, closed-loop communication and proactive weather-related operational adjustments.
- 202517 Sep
Handling alarms on the bridge – a DP incident
During scrap-metal recovery, a DPO inadvertently selected an adjacent command while trying to silence an alarm, leaving the vessel in manual mode with 10 metres of uncontrolled movement. The flash examines alarm overload, a frozen panel and inconsistent silencing arrangements, emphasising interface design, procedural reinforcement and openness within a no-blame culture.
- 2025Aug
Excavators : Use of safety control lever or isolation devices
This safety notice addresses unintended excavator movement and correct use of safety control levers or isolation devices. It describes a fatal crushing during lifting after inadvertent joystick contact caused slewing, and sets out expectations for isolation, monitoring, safe-approach communication, risk assessment and operator and slinger competence.
- 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.
- 20256 Mar
MAIB: Very serious leg injury during crane operations
An IMCA flash summarises a MAIB investigation into a second officer’s leg injury aboard Kommandor Orca. His leg was trapped in a deck crane’s rack-and-pinion traversing mechanism, requiring below-knee amputation. Findings highlight unsafe local operation, omitted permit hazards, absent onboard operating procedures and flawed training.
- 2025
MAIB Safety Digest 1/2025
A marine safety digest examining merchant, fishing and recreational vessel casualties, including collisions, groundings, fires, capsizes and people entering the water. Case lessons address navigation, mooring, towage, maintenance and emergency preparedness, with detailed discussion of flotation-device entanglement, battery charging, fuel hoses and vessel modifications. Reproduced bulletins and flyers provide further incident-specific learning.
- 202419 Sep
Injury to person during deck crane operations on board survey and supply vessel Kommandor Orca
This investigation examines a second officer’s leg injury during rail-mounted crane operations aboard Kommandor Orca at Portland. It analyses use of emergency-only local controls, entanglement in unguarded rack and pinion gearing, deficient vessel-specific procedures and training, and overlooked hazards. Company actions included remote operation, revised procedures and additional guarding.
- 20243 Sep
MAIB: vessel collision caused by mismatch between bridge and engine room control
This flash summarises a collision in Hull involving Kirkella and harbour tug Shovette after propulsion control transferred with mismatched pitch settings. It explains the automatic advance in propeller pitch and presents MAIB lessons on synchronised handover checks, documented changeover procedures, optional interlocks and advisable declutching before transfer.
- 202418 Jul
Contact with Oikos Jetty 2 by chemical tanker Ali Ka
Investigation of Ali Ka’s contact with Oikos Jetty 2 during departure from Canvey Island without tug assistance. It examines passage planning, bridge-team coordination, propulsion orders, tidal effects and ECDIS settings. Pilot fatigue was assessed as highly likely to have contributed; recommendations address fatigue management, training, tug provision and challenge resolution.
- 20242 Jul
UK HSE: Service lifts on offshore and onshore wind turbines
This flash summarises an HSE bulletin following a technician’s serious hand injury involving a wind turbine service lift. It examines inadequate landing-gate guarding and external control positioning, and relays recommendations for immediate design checks, remedial guarding or control relocation, and withdrawal or suitable short-term measures pending completion.
- 202413 Jun
Collision between fishing vessel Kirkella and pusher tug Shovette
Investigation of Kirkella’s collision with Shovette in Hull following propulsion control transfer with mismatched pitch levers. The tug partially sank and released about 7,000 litres of diesel. The report examines control interfaces, absent interlocks, handover procedures and safety management, recording interim checks and requested system modifications.
- 2024May
Service lifts in offshore and onshore wind turbines
Safety notice addressing wind turbine service-lift guarding and external control positioning after a technician sustained serious hand injuries. It calls for immediate design checks, correction of inadequate safeguards, and withdrawal or suitable short-term controls pending completion. Manufacturers and suppliers are directed to address hazards and meet machinery safety requirements.
- 20249 Jan
Chain hoist paid out unsupervised near running main engine
An unattended electric chain hoist aboard a vessel paid out onto a running main engine near the generator drive shaft. A defective pendant button issued a continuous payout command. The flash examines operator assumptions, unsecured stowage and the unused emergency stop, and recommends checks, isolation review and maintenance review.
- 2024
MAIB Safety Digest 2/2024
A collection of marine accident accounts and preventive lessons spanning merchant shipping, commercial fishing and recreational boating. Cases examine steering and propulsion failures, mooring injuries, grounding, fire, flooding and capsize. Lessons address maintenance, navigation, risk assessment, equipment interfaces, watertight integrity and emergency evacuation, alongside reproduced safety bulletins and flyers.
- 20237 Dec
Accidental discharge of condensed aerosol fire-extinguishing system on beam trawler Resurgam with loss of 1 life
Investigation of a fatal accidental aerosol fire-extinguishing system discharge during installation aboard Resurgam in Newlyn harbour. It examines electrical commissioning, generator placement, toxic combustion products and impaired escape. Laboratory trials inform analysis of inhalation hazards, while findings address installer competence, regulatory approval, contractor coordination and rescue arrangements.
- 2023Dec
Lorry loaders crush risk from powered tilting stabilisers
Safety notice addressing crushing hazards when powered tilting stabilisers on lorry loaders retract before reaching vertical stowage. It references three fatal incidents in Great Britain since 2019 and sets out manufacturer consultation, possible interlocks and control modifications, operator positioning, separate tilt and retraction operations, and training requirements.
- 202330 Nov
Yenkin-Majestic Resin Plant Vapor Cloud Explosion and Fire
Investigation of a fatal resin-plant explosion and fire following solvent vaporisation and release through an altered reactor manway. The report examines pressure-containment design, inadequate alteration assurance, agitator-dependent safeguards, alarm deficiencies and evacuation preparedness. Recommendations address low-pressure vessel guidance, safer process design and flame-resistant clothing.
- 20232 Nov
Lifeboat davit failure on polar research vessel RRS Sir David Attenborough
Investigates a lifeboat launch accident aboard RRS Sir David Attenborough that caused minor injuries to three crew. The report examines an interlock that failed to reset, likely corrosion-induced piston-rod seizure, omitted checks and maintenance, incomplete davit installation, and shortcomings in operating procedures and crew familiarisation.
- 202315 Aug
Unplanned rotation of drilling machinery
A subsea drill unexpectedly rotated during planned maintenance on a vessel’s deck, breaking retention fastenings without injuring anyone. The flash identifies an unreconciled switch position, inadequate handover and excessive reliance on administrative controls. Subsequent actions included an isolation interlock, revised switching-off procedures and improved team communication and compliance monitoring.
- 20233 Aug
Unexpected descent and ascent of mattress lifting frame
A mattress handling frame descended and abruptly ascended near divers during crane operations in active heave compensation mode. No injuries or damage occurred. The flash identifies controller-lock software interactions, obsolete operating manuals and inadequate familiarisation, with actions addressing revision control, operator briefings and protection of the controller-lock button.
- 202324 Jul
BSEE: Overhaul Ball falls to deck resulting in High Potential near miss
A safety flash describes a 350 kg crane headache ball falling 8 m during decommissioning and well abandonment, landing less than 60 cm from a rigger. A snag above the load cell masked slack developing during a blind lift. Recommendations address snag identification, slack detection, crew communication and lift planning.
- 202313 Jul
Sikorsky S-92A Exceeded Airspeed Limit During Search and Rescue Training
A Sikorsky S-92A search and rescue training flight encountered unexpected turbulence, probably associated with mountain waves near the Sperrin Mountains, and exceeded its airspeed limit. The report examines recorded flight data, wind-calculation delays and meteorological evidence. A precautionary diversion followed; inspection defects were considered probably pre-existing by the manufacturer’s representative.
- 202312 Jun
MAIB: Who is in control?
A ferry nearly grounded after confusion over transfer of propulsion control between bridge consoles. The crew regained control by zeroing the joysticks and repeating the command sequence. The flash highlights poorly visible control displays, unambiguous console indications, careful consideration of modifications and familiarity with documented recovery procedures.
- 202316 May
Close approach of AHTS vessel to offshore rig
During anchor handling, a sliding chaser collar pulled an AHTS vessel towards a rig’s mooring line. A disabled bow thruster initially prevented corrective manoeuvring; restoring all thrusters enabled safe withdrawal. The flash identifies uncommunicated machinery shutdown and missing control-transfer checks, and describes propulsion checks, bridge approval requirements and revised work instructions.
- 202310 Mar
Overhaul Ball Crashes to Deck Resulting in High Potential Near-Miss Fatality
During decommissioning and well abandonment, a snagged wedge socket released a 700-pound crane headache ball, which fell 24 feet near a rigger. The alert examines misleading load indication and blind-lift communications. BSEE recommends considering snag-point assessment, secondary slack detection, verified load movement, toolbox discussions and safe-zone planning.
- 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.
- 2023
MAIB Safety Digest 1/2023
This marine accident digest examines merchant shipping, commercial fishing and recreational boating casualties. Cases address navigation, machinery maintenance, lifting, fires and people overboard. Lessons emphasise clear control indications, practical recovery drills, effective firefighting arrangements and implementation of risk assessments, with reproduced fishing safety flyers discussing personal distress beacons.
- 202214 Jul
IOGP: Squeezed hand due to unintentional activation of winch
A crewman’s hand was squeezed between a railing and structure after he grabbed a rope moved by unintended auxiliary winch activation. The flash identifies workplace design, unidentified operational risk, incomplete role descriptions and training gaps, and recommends design improvements, disconnecting redundant levers, competence assurance and task-specific risk communication.
- 202231 May
Surface decompression near-miss
A surface decompression near-miss involved an unintended chamber depth reduction from 12msw to 5msw following a SURDO2 dive. Divers remained symptom-free. The account identifies an incompletely closed exhaust valve and supervisor distraction, and describes revised operating responsibilities, venting and depth alarms, and camera monitoring.
- 20225 May
Person overboard from motor cruiser Diamond Emblem 1 with loss of 1 life
Investigates a fatal overboard accident involving a self-drive hire cruiser on the River Bure. Embankment impact threw a passenger into the water, where rope and propeller entanglement caused injuries and drowning. Analysis examines dual-helm controls, labelling, stern protection, handover competence, risk assessment and regulatory oversight.
- 202222 Mar
MSF: Contact between Vessel and Offshore Installation
A standby vessel struck an offshore installation after watchkeeping distractions and an accidental change to emergency steering prevented forward movement being arrested. The hull was dented but not holed. The flash discusses failure to follow existing procedures, switch functionality, lookout duties, passage planning and emergency scenario training.
- 202112 Jul
Catering crew unfamiliar with firefighting systems and emergency stops
A galley water leak during vessel fire-pump testing exposed gaps in catering crew familiarity with electrical emergency stops and created potential for electrocution. An audit on another vessel identified similar firefighting awareness gaps. The flash recommends familiarisation, toolbox talks, galley fire drills and accessible, clearly marked emergency stops.
- 20211 Jul
Grounding of ro-ro freight ferry Arrow
Investigation of Arrow’s grounding in Aberdeen Harbour during thick fog examines bridge-team workload, restricted-visibility preparations and radar navigation. It analyses electronic chart system limitations, console ergonomics, passage planning and harbour arrangements. Simulator trials demonstrated benefits from separating steering and navigation. The ferry was refloated without injuries or pollution.
- 202117 Jun
Sikorsky S-92A Passed Close to Terrain in Degraded Visual Conditions
AAIB investigation of a Sikorsky S-92A serious incident near Shipston-on-Stour in degraded visual conditions. The helicopter passed within 28 ft of rising terrain without reported damage or injuries. Analysis examines manual flight, automation limitations, approach guidance, altitude alerts and crew intervention, leading to eight safety recommendations.
- 202113 Jun
Report - Error tolerance in dynamic positioning systems - November 2018
NOPSEMA examines inadvertent deactivation of dynamic positioning controls through incident database review, manufacturer consultation and a survey covering 28 Australian facilities. The report assesses double-press vulnerabilities, confirmation dialogues, alarms, protective covers and interface layouts, finding widespread additional safeguards while identifying gaps requiring further risk reduction.
- 202111 May
Crush incident on scallop dredger Olivia Jean with loss of 1 life
Investigates a fatal head injury aboard scallop dredger Olivia Jean during attempts to free snagged dredge gear. The engineer was probably struck by a towing bar swinging inboard. Analysis examines deck supervision, restricted winch-operator visibility, language barriers, training, risk reassessment and weak safety management, alongside subsequent actions and recommendations.
- 20218 Apr
Near miss: Vessel approach to wind turbine tower
Two near misses involved turbine nacelle movement during vessel approaches for offshore personnel transfer. Neither caused harm. The flash examines autonomous-mode selection, cable unwinding and alarm resetting, alongside inadequate warnings, verification, procedures and communication. It explains why turbine STOP mode is necessary for safe docking and transfer.
- 2021Apr
MAIB Safety Digest 1/2021
A marine accident digest presenting separate lessons for merchant shipping, fishing vessels and recreational craft. Cases examine unsafe access, lifting gear, engine fires, navigation, capsize and flooding. Discussions address risk assessment, supervision, casualty recovery, mooring checks and navigation aids. Appendix coverage dates refer specifically to investigations started, rather than incident dates.
- 202126 Mar
The Offshore Management of Human Factors Inspection Guide
Inspection guidance for assessing human factors management in UKCS offshore oil and gas operations. It sets success criteria for critical task analysis, procedures, competence, fatigue, handovers, staffing, organisational change, interfaces and alarms. Qualitative analysis underpins quantitative assessment, while inspection scoring accounts for the scope inspected and cumulative risk gaps.
- 202125 Mar
Inadquate operation of circuit breaker
A maintenance worker checking a compressor breaker during an annual inspection disengaged it, triggering alarms and facility downtime without injury or equipment damage. The alert examines ambiguous switchboard labels, indicator colours and missing procedures, and asks operators to consider training, updated documentation, pre-job meetings and protective button coverings.
- 202111 Feb
Failure of remote control/emergency stop on rescue boat winch
During rescue-boat recovery, remote control and emergency-stop functions failed, and the limit switch did not stop retrieval. Inspection found a contactor stuck closed; frequent short switching intervals were considered the most probable cause. The flash emphasises correct retrieval procedures, component inspection and replacement, and regular emergency-stop function testing within planned maintenance.
- 2021
MAIB Safety Digest 2/2021
A collection of merchant, fishing and recreational vessel cases examines navigation errors, mooring hazards, machinery fires, flooding and immersion. Lessons address task planning, supervision, maintenance, enclosed-space precautions and emergency readiness. Appendices list investigations and reports and reproduce provisional guidance on anchor failures during prolonged cruise-ship anchoring.
- 202010 Nov
Main crane hoist wire damage
A crane hoist wire was damaged by rubbing against a knuckle aperture after the operator disengaged automatic knuckle control to activate heave compensation. The flash describes subsea wire cutting, onboard re-socketing and downtime, alongside familiarisation constraints, ignored alarms and recommendations to improve the operator interface and reinforce adherence to manufacturer instructions.
- 202027 Oct
Work Platform Dropped Into Sea
An alert describes a BOP trolley work platform dropping into the sea after its operator selected the wrong control lever while attempting to move closer to the riser. The action released securing pins. Two personnel were restrained by self-retracting lifelines and recovered without injury.
- 20209 Oct
Dropped object – Wireless crane control unit
A wireless crane controller fell almost seven metres through a hatch after its waist-belt buckle failed. Two riggers remained outside the dropped-object exclusion zone. The flash recommends securing-mechanism inspection and planned replacement, reinforces pre-use checks, and calls for consideration of secondary retention and review of hatch kick boards.
- 2020Oct
MAIB Safety Digest 2/2020
A collection of marine accident lessons covering merchant vessels, commercial fishing and recreational craft. Cases examine collisions, grounding, machinery failures, overboard accidents, scalding and fire. Discussions address navigation information, lifejackets, maintenance checks and recovery arrangements. An appended provisional bulletin considers precautions for condensed aerosol fire-extinguishing systems.
- 202015 Jul
Near miss between ro-ro ferry Stena Superfast VII and Royal Navy submarine
This investigation examines a North Channel near miss between Stena Superfast VII and a submerged Royal Navy submarine. It analyses inaccurate range and speed assessments, periscope watchkeeping supervision, electronic contact information and cancellation of a close quarters procedure. Reported actions address simulator training, procedural adherence and risk assessment.
- 202027 May
Blow Out Preventer (BOP) Drops to Seabed
This alert describes a blowout preventer falling to the seabed during deployment on marine riser. A subsea engineer inadvertently triggered the emergency disconnect sequence after mistaking its button for the wellhead connector valve override, separating the preventer from the lower marine riser package.
- 202021 May
Engineering and design information paper
This information paper explains how human factors can be integrated into offshore petroleum facility design to reduce error and support recovery. It examines control rooms, panels, software displays and alarm rationalisation, alongside maintainability, equipment accessibility and escape routes. Recommendations address human factors involvement throughout the project lifecycle.
- 202028 Apr
Near miss: Dropped clump weight
A clump weight fell approximately 30 m to the deck, landing around a metre from a rigger after unintended tugger winch activation pulled rigging against a sheave and released a wedge socket connection. The flash examines control positioning, changed rigging arrangements, risk assessment and management of change.
- 202017 Mar
Trencher angle inadvertently altered
Accidental joystick activation during offshore trenching raised the cutting wheel and reduced cutting depth, unnoticed during a shift handover and computer reboot. No equipment or permanent material damage occurred. The flash examines interface design and alarm tolerances, describing revised alarm settings, cessation of trenching during handovers and joystick deactivation.
- 202013 Feb
Collision between bulk carrier Gülnak and moored bulk carrier Cape Mathilde
This investigation examines Gülnak’s collision with the moored Cape Mathilde at Teesport after an intended port turn could not be arrested. It analyses shiphandling, steering, engine indications and hydrodynamic effects without identifying a direct cause. Missing recorded data limited verification; recommendations address manoeuvring data and bridge equipment checks.
- 202012 Feb
Safety Alert 376 - Rig Floorman Pinned by Moving Equipment
A rig floorman suffered a major lost-time injury when an Iron Roughneck control panel pinned him against a guide roller assembly after its travel switch failed to return to neutral. BSEE recommends considering design and layout changes, checking control functionality, evaluating proximity switches and delineating unsafe operating areas.
- 201917 Dec
Vessel hit and destroyed fender
A vessel approaching harbour struck the quay and destroyed its fenders during a changeover to bridge wing control. Wind and current forced the vessel to starboard, while crew distraction reduced attention to its movement. The flash calls for crew review of contributing factors and lessons learnt.
- 201912 Nov
Near miss: Emergency stop pressed accidentally
A vessel’s port azimuth thruster stopped during dynamic positioning when a passing crew member accidentally struck its emergency stop with his elbow. The vessel safely withdrew from the 500m zone. The flash identifies ineffective switch guarding and calls for similar emergency stop buttons across vessels to be identified and replaced.
- 201930 Sep
Loss of rig anchor wire from vessel Karm Fork
During a rig move, accidental operation of the wrong Karm Fork emergency release allowed anchor wire and chain to slip into the sea. Preliminary findings identified communication and procedural failures. Actions included revising the operations manual and task risk assessment, relocating CCTV, and reiterating that commands must come from the Master.
- 20194 Sep
Listing of crew boat due to water ingress
A crew boat listed on its first voyage after dry-docking when water entered a starboard void space. The flash describes valve installation and gasket defects, a visual-only bilge alarm and a pump control in manual mode. It highlights absent post-drydock inspection and testing, and subsequent pre-sail checks.
- 201923 Aug
Accidental activation of emergency stop during saturation diving operations
Accidental operation of unprotected emergency-stop buttons stopped both lubricating-oil pumps and tripped a vessel’s starboard Voith Schneider propulsion during saturation diving. The vessel maintained position and divers were safely recovered without injury. Lessons address button covers, situational awareness, shipboard familiarisation, and more thorough job safety analysis and toolbox talks for routine engine-space maintenance.
- 20198 Aug
Sikorsky S-92A Wrong-Deck Approach During Offshore Shuttling
Investigates a Sikorsky S-92A wrong-deck approach during shuttling in the Brae field. Platform similarity and alignment, training workload and expectation biases weakened identification checks. The report examines flight management cues, helideck directories and operating procedures, describes the radio operator’s intervention, and records planned training and checklist reviews.
- 201916 Jul
High potential near miss: Dropped object during piggyback drilling operations
A safety flash describes inadvertent sample-winch activation during piggyback drilling. An 11 kg overshot snagged on a ladder safety hoop, separated from its wire and fell approximately 8 m, without injury or damage. Lessons address console ergonomics, design risk assessment, familiarisation assessment and preventive maintenance documentation.
- 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.
- 201928 May
High potential near miss – unsecured sheave
This safety flash describes a vessel near miss in which inadvertent control activation moved a power swivel, changing a tagline’s orientation and opening a sheave gate. A 40 kg assembly remained suspended above crew. Lessons address console design, sheave installation standards, operator visibility and clearer responsibilities across overlapping operations.
- 201928 May
Partial pressure of oxygen (PPO₂) getting low in bell
During saturation diving at approximately 147 msw, oxygen partial pressure fell in a bell and the main oxygen bottle was subsequently found empty. The flash describes breathing-mix purging, BIBS use and recovery, followed by changes to oxygen make-up responsibilities, panel positioning, valve configuration and buffer-tank connections.
- 20193 May
Unsafe actions and conditions – Inhibited alarm buttons
A vessel safety walk-round identified alarm acknowledgement and mute buttons held down with toothpicks and adhesive tape. The flash stresses the importance of prompt attention to visual and audible alarms for protecting people, equipment and vessels. The affected alarms were not fire alarms.
- 201912 Mar
Galley safety – rice cooker smouldering
An unused rice cooker was likely activated unintentionally through controls exposed to passing pedestrians. With no rice or liquid present, heat accumulated and its rubber seal smouldered. No injury or major outcome resulted. Lessons address unplugging equipment during prolonged disuse, protective barriers and area inspections.
- 201921 Feb
Contact and grounding of ro-ro passenger ferry Pride of Kent
Investigation annexes trace Pride of Kent’s manoeuvring from a berth through contact and grounding. The chronology records reduced port-engine shaft speed, loss of a bow thruster, transfer of steering control and rudder synchronisation. A separate annex presents wind speed and direction using the ship’s anemometer data.
- 201820 Jul
Vessel collision with fixed structure on wind farm
A vessel struck a wind turbine transition-piece platform twice after changing from dynamic positioning to independent joystick control in worsening weather. Thrusters returned to zero pitch during changeover. The flash examines handover awareness and judgement, subsequent system testing, and revisions to procedures, familiarisation and passage planning.
- 201827 Jun
Grounding and loss of commercially operated yacht CV24
Investigation of CV24’s grounding and loss off Cape Peninsula during the Clipper round the world race. It examines positional awareness, competing navigation and deck-supervision demands, electronic chart access, passage planning, manning and safety management. The crew were rescued uninjured; recommendations address navigation procedures, training and organisational assurance.
- 20189 May
Grounding of general cargo vessel Islay Trader
Investigation of Islay Trader’s grounding off Margate after dragging anchor and attempting to reposition. It examines insufficient anchor cable for tidal conditions, neglected position monitoring, bridge workload and failure to seek the master’s assistance. Paper-chart navigation, radar monitoring and Schottel controls are discussed, with recommendations addressing anchorage planning and watchkeeping standards.
- 201822 Mar
Aircraft Accident Report 1/2018, G-WNSR High resolution
Investigation of G-WNSR’s loss of yaw control during landing at West Franklin. A failed tail rotor pitch change shaft bearing damaged the control servo; the initiating reason remained undetermined. The report examines missed HUMS warnings, software interfaces, maintenance review and crew decisions, documenting safety actions and recommendations. No injuries occurred.
- 20172 Nov
Collision between high-speed passenger catamaran Typhoon Clipper and workboat Alison
Investigation of a passenger catamaran and workboat collision beside Tower Millennium Pier on the River Thames. It examines obstructed visibility, CCTV display limitations, distracted lookout and absent sound signals, alongside workboat management deficiencies. The report also analyses crew rescue, emergency drills and the risks of cold-water immersion without flotation devices.
- 201720 Oct
Stored energy near miss: Person nearly hit by equipment caught during light daughtercraft operations
A stand-by diver narrowly avoided a block and tackle projected when a mooring line caught a deployed rescue davit on a light daughtercraft. The flash examines hurried transit preparations, restricted monitoring and procedural gaps, and records revised departure hold points, operating checklists and practical familiarisation requirements.
- 201714 Sep
AW139 Landed on Wrong Helideck Following Incorrect Destination Selection
An AW139 landed at Leman 27B rather than Shell Leman 26B after an incorrect destination was selected during manual flight planning. The investigation examines incompatible helideck codes, dropdown selection, passenger manifests and radio calls. Operator actions included secondary flight-plan checks, coding reviews and crew access to coding information.
- 201713 Sep
Loss of control and grounding of ro-ro passenger ferry Hebrides
Investigation of Hebrides’ loss of propeller pitch control approaching Lochmaddy, followed by pontoon damage, grounding and pier contact. It examines actuator setscrew loosening, missing maintenance instructions, unimplemented control upgrades and difficulties coordinating emergency actions. Recommendations address propulsion-failure drills, contingency planning and handling manufacturers’ advice.
- 20172 Aug
Hand injury whilst using pillar drill
An engineer changing a pillar-drill bit inadvertently started the machine, catching his glove and injuring his hand. The flash examines unmarked controls and unclear emergency-stop and energisation indications. It records familiarisation training and recommends risk assessment, alongside function checks of guard interlocks fitted to a newer model.
- 201725 Jul
Unsafe mooring practices
A vessel inspection identified ropes attached to mooring winch levers for improvised remote operation. The flash highlights unintended activation, crew entanglement and inadequate winch control. It recommends sufficient personnel supervised by a certified officer for equipment handling, communications and directing the winchman.
- 20176 Apr
Contact made by passenger ferry Uriah Heep with Hythe Pier
Investigation of Uriah Heep’s collision with Hythe Pier during berthing examines water jet propulsion controls, hydraulic failure modes and restricted manoeuvring space. The precise fault remained unidentified, although hydraulic mechanical failure was considered almost certain. Seated passengers received warning before impact; no recommendations followed the actions taken.
- 201721 Mar
Near miss: Emergency fire pump could not be started from the bridge
During a vessel fire drill, an emergency fire pump could not be started from the bridge because its switch was set to local control. Switching to bridge remote restored operation. The flash discusses missed checks, unused stop-work authority and communication failures, emphasising genuine testing and thorough recorded handovers.
- 20173 Mar
2017-001 KC 96 Investigation of October 20, 2015 Fatality During Pipe Handling, Lease OCS-G 33531, Keathley Canyon Block 96 Drillship Pacific Santa Ana
BSEE investigates a fatal pipe-handling incident aboard Pacific Santa Ana during tripping operations. A failed fingerboard latch seal allowed a latch to close, obstructing a pipe stand that bowed and recoiled into a floor hand. The report examines control-display limitations, task allocation, risk assessment, training and supervision.
- 201619 Dec
Some Ergonomic Issues of DP Vessel Controls
This safety alert examines accidental disengagement of dynamic positioning on a semisubmersible drilling rig and delayed recognition of manual control. It identifies inadequate button protection and unclear mode displays, and calls for operators to review control ergonomics, alert crews to weaknesses and make appropriate improvements.
- 20163 Oct
Collision between vessels
A survey vessel collided with a moored pipe-carrying vessel while manoeuvring within an anchor pattern for a crew change. Investigation identified loss of azimuth thruster control, possible autopilot and interface design issues, and breaches of speed and heading procedures. The definite cause of control loss remained unresolved.
- 201627 Jun
Vessel loss of position while diving in close proximity to a hydrocarbon facility
A diving vessel drifted over 40 metres after inadvertent deselection of its surge control disabled automatic positioning. A diver noticed his umbilical becoming taut. The alert examines vulnerable console layout, absent confirmation and ineffective excursion feedback, highlighting interface design and safeguards against unintended deactivation.
- 20169 Jun
AW139 Landed on Wrong Offshore Platform During Line Training
An AW139 carrying ten passengers landed on Amethyst A1D instead of A2D during line training. The report examines similar platform appearances, flight-display waypoint presentation and destination-identification checklists. The crew attributed the error to early misidentification and considered simulator identification practices a possible contributory factor. No injuries or damage were reported.
- 20169 Jun
Sikorsky S-92A Landed on Wrong Offshore Helideck
Investigation of a Sikorsky S-92A landing on the unmanned Ensco 120 helideck rather than Buzzard in the North Sea. It examines visual misidentification, crew workload, radio interruptions, unused flight-management information and the decision to depart immediately. Potential safety actions concern navigation cross-checks, approach checklists and training.
- 201612 May
Girting and capsize of mooring launch Asterix
Investigation of Asterix’s girting and capsize during harbour towage at Fawley Marine Terminal. It examines towline geometry, gog-rope arrangements, unsuccessful manual towing-hook release and subsequent flooding. Findings address operational communication, crew training, control layout, release testing and watertight closures; both crew members survived following rescue.
- 20166 May
First aid injury: Person struck by wire under tension
A crew member suffered minor abrasions when a slack tagging wire became taut during preparations to transfer an inline tee between vessels. The flash examines constant-tension winch operation, control-panel design, supervision and training deficiencies, and presents recommendations on equipment testing, risk assessment, staffing and emergency-stop placement.
- 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.
- 201616 Mar
Listing, flooding and grounding of vehicle carrier Hoegh Osaka
Investigation of Hoegh Osaka’s stability loss, flooding and grounding in the Solent. It examines cargo distribution, inaccurate cargo and ballast data, omitted cargo centres of gravity and missing departure stability verification. Independent modelling informed the analysis; cargo shift was most likely consequential. The report also reviews securing arrangements, evacuation and revised operational procedures.
- 201615 Mar
Super Puma Sea Impact During Non-Precision Approach to Sumburgh
Investigation of G-WNSB’s sea impact during a non-precision approach to Sumburgh, with four passenger fatalities. It examines ineffective instrument monitoring, approach procedures and automation use through recorded flight data and human-performance studies. Survivability analysis addresses underwater escape, emergency breathing systems, flotation, liferaft deployment and rescue, alongside recommendations and subsequent safety action.
- 201519 Nov
Contact made by ro-ro passenger ferry Dover Seaways with a breakwater
This investigation examines Dover Seaways’ contact with Dover’s South Breakwater following an unintended transfer of steering control to a trackpilot. The transfer’s cause remained unidentified. It analyses bridge-team system knowledge, delayed stopping actions, ineffective anchor deployment and absent passenger warnings, recommending improved emergency training and procedures for timely warnings.
- 20158 Oct
Fatal AW139 Accident During Departure in Darkness and Fog
An AAIB investigation examines the fatal AW139 departure near Gillingham Hall in darkness and fog. Recorded flight data and wreckage examination inform analysis of abnormal pitch, possible somatogravic illusion, crew co-ordination and automatic flight control use. The report also considers private-operation oversight, departure visibility requirements and two-pilot training.
- 20157 Oct
Disabled and Non-Functional Safety Devices Leads to Destruction of Derrick Board
A drilling alert describes elevators bending a derrick diving board as the drill string was lowered. The driller attempted to float the elevators but did not notice that they remained extended. The link-tilt warning light was non-functional, and the electronic anti-collision shutdown system had been manually switched off.
- 201517 Jun
Collision between passenger vessel Millennium Time and motor tug Redoubt
Investigation of a Thames collision involving Millennium Time, Redoubt and towed barges, leaving nine passengers with minor injuries. Analysis examines steering responsiveness, absent rudder indication, helm competence, supervision and possible hydrodynamic interaction. It also addresses evacuation readiness, watertight-integrity checks and inaccurate passenger reporting, with steering trials informing subsequent improvements.
- 20154 Jun
Accident to skipper of scallop dredger Ronan Orla with loss of 1 life
MAIB investigates fatal winch entanglement during single-handed scallop dredge recovery aboard Ronan Orla off north Wales. The exact snagging mechanism remained inconclusive. Analysis examines poor winch condition, inaccessible controls, absent emergency stops and lone-working risks, with recommendations addressing safety training and fishing-vessel self-certification.
- 20158 May
Near-miss incidents: Crew transfer vehicles approaching wind turbines
Three crew transfer vessel incidents concern loss of alignment at wind turbine boat landings and steering faults. Two involved near collisions with monopiles; investigations of steering failures identified worn potentiometers. Recommendations address clearing the transfer platform, stopping transfers before repositioning and considering planned maintenance or replacement of control units.
- 20155 Mar
Contact made by passenger vessel Millennium Diamond with Tower Bridge
This investigation examines Millennium Diamond’s contact with Tower Bridge on 4 June 2014, injuring ten passengers and crew. It analyses distraction during VHF replay, wheelhouse ergonomics, ineffective public-address warnings and unexpected pier closure. Recommendations address equipment layout, holding areas and boatmaster training; unsecured catering equipment is also examined.
- 201512 Feb
Accident while emptying catch from dredges on scallop dredger Wanderer II with 1 person injured
Investigation into a deckhand’s serious hand injury during scallop dredge emptying aboard Wanderer II. It examines rope entrapment at a whipping drum, inaccessible winch controls, training and risk-assessment shortcomings. The report discusses rope guides, captive-drum conversion and arrangements for trained operators and crew communication.
- 201410 Dec
Super Puma Sea Impact During Night Approach to Offshore Platform
Investigation of G-REDU’s sea impact during a night approach to ETAP examines crew misperception, approach monitoring, unavailable height warnings and survival arrangements. Recorded flight data, avionics memory extraction, simulations and specialist illusion analyses inform findings. All occupants were rescued uninjured; recommendations address approach procedures, warning systems, evacuation and rescue equipment.
- 201410 Dec
Two EC225 LP Helicopter Ditchings in the North Sea
Combined investigation of two EC225 LP helicopter ditchings in the North Sea in 2012. Corrosion-pit initiated fatigue failures interrupted gearbox oil-pump drive. The report examines stress modelling, welding residual stresses, condition monitoring, misleading emergency lubrication warnings, evacuation and liferaft deployment, and records corrective actions and safety recommendations.