Equipment
Valve
Devices controlling or isolating fluid flow.
Newest 100 Documents
All 774 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.
- 202610 Aug
United States Steel Corporation Clairton Plant Coke Oven Explosion
Investigates the fatal Clairton coke works explosion during high-pressure water washing of a cast-iron isolation valve. Overpressurisation caused valve failure and a coke oven gas release. The report examines maintenance procedures, hazard assessment, occupied-building siting and process safety governance, supported by valve examination and causal analysis.
- 202627 May
Givaudan Sense Colour Explosion
Investigation of a fatal reactor explosion during caramel colouring manufacture in Louisville. A vent valve failed closed, accelerating sugar decomposition; cooling and emergency pressure relief capacity were inadequate. Calorimetry and component testing inform findings on reactive hazards, process safety implementation, operating limits, occupied-building siting and regulatory coverage gaps.
- 202614 May
Shifting cargo and deck spill during heavy weather
During heavy-weather transit, a brine storage tank shifted approximately 0.5 m, struck a crash rail and damaged its manifold valve, spilling brine onto the deck. The flash identifies slackening lashing chains and inadequate securing, and recommends redundant lashings, impact protection for vulnerable fittings and review of weather risk assessments.
- 202628 Apr
BSEE Safety Alert 516 - BSEE Identifies Compressed Gas Cylinder Hazards During Risk-Based Inspections
Following reported cylinder-failure explosions, BSEE inspected 20 Gulf assets and identified gaps in cylinder marking knowledge, inspection programmes, maintenance and contractor assurance. The alert presents findings on storage, corrosion and recharging, and asks operators and contractors, where appropriate, to consider improved labelling, documented inspections, overpressure protection and training.
- 20262 Apr
Foundering of the fishing vessel Freedom II (CN 111)
Investigation of Freedom II’s foundering off western Scotland identifies suction-pipe fatigue failure as the most likely flooding source. It examines overwhelmed and unavailable pumps, progressive flooding, seawater isolation, emergency preparedness and delayed distress alerting. All crew were recovered uninjured; actions already taken led to no new recommendations.
- 2026Apr
Emergency response systems save lives! — Process Safety Beacon, April 2026
This issue examines an ammonia release at a Virginia food processing facility where evacuees encountered the outdoor cloud and four employees were hospitalised. It highlights shortcomings in alarms, emergency shutdown use and release-specific planning, emphasising trained responders, regular drills, safe relief discharge locations and wind-dependent evacuation routes.
- 2026Mar
Production PINCs
Numbered regulatory inspection questions address production safety systems, well barriers and casing-pressure diagnostics. Checks cover shutdown valve operation, gas and fire detection calibration, firewater pumps, pressure relief and protective devices on process equipment. Conditional approval requirements and specified testing intervals support inspection of production facilities and subsea components.
- 202626 Feb
Dow Louisiana Operations Explosions
Investigation of the Dow Plaquemine explosion examines work lights left inside a reflux drum during turnaround. Degraded light debris punctured a rupture disc, admitting ethylene oxide into air-containing relief piping. The report analyses vessel closure practices, loss of nitrogen inerting, inadequate monitoring and relief routing that enabled propagation into the drum.
- 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.
- 202613 Feb
BSEE: Miscommunication and trapped pressure causes injury during valve maintenance
An offshore valve-maintenance incident injured a worker when trapped gas pressure ejected a bonnet flange. This flash summarises BSEE findings on incomplete authorisation, inadequate isolation verification, miscommunication, unsafe scaffold use and omitted retaining nuts. Recommendations emphasise confirming zero stored energy, reviewing task assessments, following manufacturer instructions and considering two-person working.
- 202613 Feb
Small engine room fire – flammable object ignited
A small flammable foreign object ignited during post-drydock engine load testing. The crew stopped the engine, isolated fuel and extinguished the fire; nobody was injured. The flash identifies poor housekeeping and absent post-maintenance checks, emphasising machinery-space cleanliness, checks before load testing and regular emergency drills.
- 202629 Jan
Flooding and foundering of stern trawler Opportune (LK 209)
Investigation of Opportune’s foundering east of Lerwick following uncontrolled engine-room flooding. Seawater pipework failure was considered the most likely cause, but remained unconfirmed. The report examines pipework inspection, inaccessible sea inlet valves, lack of remote bilge-pump operation and flood preparedness. All eight crew were rescued uninjured from liferafts.
- 202622 Jan
Fall from a pilot ladder while attempting to board the cargo vessel Finnhawk from the pilot vessel Humber Saturn with loss of 1 life
Investigation of a fatal pilot boarding accident involving Finnhawk and Humber Saturn. A probable cardiac event preceded the fall, while recovery-platform failure left the injured pilot partially immersed for over 40 minutes. The report examines medical fitness assessment, hydraulic defects, maintenance, cold-water protection and rescue training.
- 2026Jan
D-PINCs (Operators Version - Jan 2026) — Drilling
A regulatory checklist for oil and gas drilling, linking numbered compliance questions to statutory authorities and enforcement actions. It addresses approvals, diverter configuration and testing, casing installation, cement placement, drilling-fluid management and monitoring. Further checks cover ventilation, gas detection, ignition prevention and retention of drilling and test records.
- 2026Jan
Well Operations
An inspection guide presenting compliance questions for well operations under Subpart G, with regulatory authorities and enforcement codes. It covers casing and liner integrity, surface and subsea blowout preventer configuration, pressure and function testing, maintenance and records, alongside specific requirements for coiled tubing and snubbing systems.
- 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.
- 202518 Dec
Two Walk-to-Work gangway incidents
Two related Walk-to-Work gangway incidents occurred during offshore wind personnel transfers. Hydraulic stiction caused uncontrolled slewing and a collision with the vessel crane. Subsequent modifications introduced an automation logic error that prevented retraction during connection preparation. The flash describes hydraulic adjustments, revised operating procedures and manufacturer testing; neither incident caused injury.
- 202517 Dec
Capsize and foundering of the prawn trawler Odyssey (FR 70)
Investigation of Odyssey’s capsize during net recovery in the North Sea. Wash water accumulated on the shelter deck, with a tonnage valve likely obstructed, causing loss of stability. Stability modelling, pump controls, drainage arrangements and emergency preparedness are examined. All six crew abandoned to a liferaft and were rescued uninjured.
- 20254 Dec
Fire in the engine room – fuel spray fire
Fuel sprayed onto hot surfaces of a starboard main engine after maintenance left return-pipe bolts missing and protective barriers absent. Crew extinguished the fire without injuries or pollution, but water mist failed and shutdown actions were delayed. Lessons emphasise post-maintenance checks, splash protection and familiarity with emergency equipment.
- 20253 Dec
BSEE Safety Alert - 509 - Miscommunication and Trapped Pressure Causes Injury
An offshore contractor was injured when trapped gas pressure ejected a bonnet flange during control-valve maintenance. The alert identifies unverified isolation, missing authorisation, miscommunication, unsafe scaffold use and omitted retaining nuts. Recommendations address zero-energy verification, collaborative job safety analysis, operational support, fall protection and adherence to manufacturer procedures.
- 20257 Nov
ATSB: Undocumented modification contributed to steam burns
An oil tanker maintenance team suffered burns when hot condensate escaped during steam valve bonnet removal. The ATSB found insufficient cooling time and an undocumented drain-line modification that likely weakened isolation. The flash highlights formal management of change, recording and assessing changes, adequate cooling and visual confirmation of isolation.
- 2025Nov
PPE only works when you wear it correctly! — Process Safety Beacon, November 2025
This Beacon examines a California refinery release during pressure-gauge replacement, where ineffective isolation and absent respiratory protection increased harm from hydrogen sulphide exposure. It explains limitations of personal protective equipment and stresses task-specific procedural requirements, correct use, pre-use inspection and regular checks of condition and respirator cartridge expiry.
- 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.
- 202525 Sep
Cuisine Solutions Ammonia Release
CSB investigates an ammonia refrigeration release at Cuisine Solutions in Sterling, Virginia, which injured workers during evacuation. Relief-valve testing and dispersion modelling examine overpressure, liquid aerosol and unsafe discharge. The initiating upset remains undetermined. Recommendations address relief-system assessment, process-data retention, ammonia alarms and emergency preparedness.
- 20254 Sep
MSF: Grease gun hand injury
A crew member suffered a grease injection injury through a glove while disconnecting a battery-powered grease gun hose during tensioner maintenance. The flash reports a malfunctioning pressure release valve and possible handling and training shortcomings. Lessons emphasise manufacturer instructions, pre-use hose and nipple inspections, suitable gloves and consideration of safer tools.
- 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.
- 20251 Aug
BSEE Safety Alert - 504 - Malfunction of Rental Generator's Engine Air Shutoff System
A rental generator fire on an offshore platform followed a closed right-bank air flap, allowing unburnt diesel and excess oil to accumulate and ignite with heat from the operating left bank. The alert recommends considering improved maintenance checks, alarm verification, training and procurement assurance, including independent testing of each emergency air flap.
- 2025Aug
Thermal Expansion runs hot and cold! — Process Safety Beacon, August 2025
This bulletin explains how heating trapped liquids and freezing accumulated water can rupture process pipework. Two chemical-processing incidents illustrate releases, fires and injuries involving a burst strainer and cracked propane piping. It highlights pressure relief, established isolation and depressurisation procedures, accommodation of thermal movement and temperature-dependent freezeproofing.
- 202518 Jul
Capsize and sinking of fishing vessel Njord with loss of 1 life
Investigation of Njord’s capsize and sinking while processing a large catch, with one crew member drowning. Analysis examines catch loading, downflooding through an open drain valve, vessel modifications and stability-book assumptions. Indicative digital stability modelling supports the findings, alongside examination of flotation protection, liferaft deployment, emergency communications and rescue.
- 20253 Jul
High potential incident: Worker injured when opening a flanged assembly
A worker dismantling emergency shutdown valves on deck sustained a forehead wound when trapped line pressure expelled a gasket. The flash identifies missing pressure checks and monitoring after isolation, alongside water ingress during subsea diving work. Actions included supervised pre-start checks, pressure-checking and venting hold points, and closer line monitoring.
- 2025Jul
Hydrocarbon Active Fire Protection
An inspection guide for offshore hydrocarbon fire protection, setting out regulatory expectations, success criteria and dutyholder scoring. It examines firewater pumps, ring mains, deluge coverage and chemical dosing, with emphasis on corrosion, marine growth, system availability, as-found testing and investigation of recurring blockages.
- 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.
- 20253 Apr
BSEE Safety Alert 498 - Explosion and Fire Incident
A liftboat explosion during separator draining injured two workers with burns. Gas accumulated on deck and a generator surge triggered ignition. The alert examines tank sealing, unsuitable gas detectors, failed air-intake shutoff controls and delayed medical evacuation, recommending that operators consider improved procedures, inspections, testing and emergency arrangements.
- 2025Apr
Knowing ‘why’ makes tasks safer — Process Safety Beacon, April 2025
This bulletin compares valve actuator removal incidents in La Porte in 2021 and Baton Rouge in 2016. It highlights missing procedures and training, and stresses understanding why critical tasks follow specified steps. Recommendations include illustrated instructions, signed checklists, demonstrated competence and checking procedures against field conditions.
- 202513 Mar
Marathon Martinez Renewable Fuels Fire
Investigation of a renewable diesel startup fire at Martinez, California, following heater tube rupture. Low process flow and afterburning caused overheating, releasing diesel and hydrogen and seriously injuring an operator. The report examines valve alignment, instrumented safeguards, combustion monitoring, alarm responses, human factors and corporate oversight, with recommendations and comparisons to earlier incidents.
- 202526 Feb
Contact with pier by paddle steamer Waverley
Investigation of Waverley’s contact with Brodick pier on 3 September 2020, injuring 24 passengers and crew. Engine dead centre delayed astern propulsion. The report examines piston valve securing, lost engineering expertise, informal training and unassessed closed-end berthing risks. It records subsequent maintenance and operational changes, with no recommendations made.
- 20256 Feb
Saturation diver exposed to chemicals from pipeline
A saturation diver suffered chemical burns after exposure to chemically treated seawater while disconnecting a pigging/flushing hose during decommissioning. The flash identifies uncertainty over flushing and absent engineered barriers. Lessons address understanding pipeline contents, hazard analysis, amended procedures, valve isolation and securing, and reducing exposure through local valves.
- 2025
2 - Integrity management of FPSOs/FSUs
OMAR guidance addresses structural and maritime integrity of UKCS FPSOs and FSUs, drawing on regulatory interventions. It discusses inspection regimes, hull loading, watertight integrity, cargo systems and station keeping, alongside competence, independent verification and safety-case review. Ageing assets and formal life-extension assessments receive particular attention.
- 2025
CHIRP Maritime FEEDBACK 78 (Spring 2025)
This maritime digest examines pilot-ladder deficiencies, a caustic eye injury, unacceptable accommodation, charcoal cargo fire, corroded walkways, yacht fire, disabled carbon dioxide firefighting and rescue-craft capsize. Commentary emphasises time for post-maintenance checks, equipment handovers, crew training and risk assessment, alongside protective equipment and seafarers’ rights.
- 202414 Oct
Fire in engine room
A vessel engine-room fire was most likely caused by a fuel leak following pipe misalignment during reassembly. Blocked detection tubing and drains, unavailable water-mist suppression and delayed ventilation shutdown contributed to escalation. The flash highlights correct assembly, regular inspections, fire drills and checks of emergency procedures.
- 202414 Oct
Inappropriate automatic activation of fixed fire-fighting system
A harbour tug’s fixed engine-room firefighting system discharged all its gas after two blackouts within 24 hours. Activation was linked to a battery-voltage rise following a pilot-cylinder solenoid valve malfunction. Nobody was harmed. Lessons address electrical supply adequacy, emergency-system functionality and blackout drill protocols.
- 2024Oct
Some short-cuts may cut lives short — Process Safety Beacon, October 2024
This bulletin examines procedural shortcuts through a fatal polyethylene reactor incident in Pasadena, Texas. It describes inadequate isolation, unenforced permits and cross-connected valve air hoses. Guidance stresses operational discipline, functioning safeguards and authorised assessment of changes, warning against treating temporary safeguard bypasses as routine practice.
- 202425 Sep
Tampering with approved safety devices
A client inspection found a homemade clamp holding open a self-closing valve on a vessel’s lubricating oil storage tank. Installed to save time, the modification had escaped routine checks. The flash highlights safety-device integrity, adherence to procedures and proper approval or management of change for equipment modifications.
- 202414 Aug
MSF: Serious hand injury – high pressure air
During a vessel fire drill, a crewmember assisting with breathing apparatus suffered a finger injury from high-pressure air released through a cylinder valve’s pilot vent hole. Surgical treatment was required. The flash relays MSF recommendations on connection tightening, leak checks, breathing checks and low-pressure alarm testing.
- 202424 Jun
BP - Husky Oregon Chemical Release and Fire
Investigates the fatal naphtha release and flash fire at the BP-Husky Toledo Refinery in Oregon, Ohio. Examines cascading process disturbances, vessel overflow, manual draining, misleading level indications and alarm overload. Recommendations address engineered overfill safeguards, abnormal-situation procedures, stop-work practice and alarm performance, alongside shortcomings in applying earlier incident lessons.
- 202416 Apr
BSEE Safety Alert - De-pressurizing Piping to Remove Hydrate Results in an Injury
An offshore platform operator suffered bruising and swelling when a ball valve assembly separated during depressurisation of gas lift piping containing a possible hydrate. Approximately 900 psi remained trapped behind the valve. The alert discusses inadequate isolation, missing task hazard analysis, and measures operators should consider for hydrate prevention and safe pressure bleeding.
- 202416 Apr
Improperly Depressurizing Piping to Remove a Hydrate Causes Injury
An offshore platform operator suffered bruising and swelling when a valve assembly detached during depressurisation of gas lift piping containing a possible hydrate. Approximately 900 psi was trapped behind the valve. The alert recommends considering energy isolation, balanced bleeding, task hazard analysis, management of change and gas dehydration.
- 202427 Mar
Implosion of chemical tank
A chemical tank on a vessel imploded after pumping created a vacuum with its manual air inlet valve unopened. Around two cubic metres of monoethylene glycol spilled onto the deck and into the sea; nobody was injured. The flash examines unfamiliar replacement equipment, supplier assurance, documentation, familiarisation and management of change.
- 202419 Mar
High potential: sea water inlet pipe leakage in engine room
A vessel crew discovered seawater leakage from corroded air-conditioning condenser pipework near the hull while offshore. A cement box contained the leak before emergency dry-docking for repairs. The flash identifies missing documented condition checks and recommends regular inspection of ship-side valves and piping within planned maintenance.
- 202422 Jan
MSF: LTI – Engineer scalded
An engineer aboard a platform supply vessel suffered scalding burns when a cooling-water compensator burst during refilling after repair. The flash discusses sudden pressure increase, unsuitable temperature rating, likely material degradation and potentially inadequate pressure relief. Corrective measures address compensator suitability, installation checks, cooling before refilling and planned inspection and maintenance.
- 202326 Dec
Wendland 1H Well Fatal Explosion
CSB investigates a fatal blowout and fire during tubing-head replacement at a Texas oil and gas well. It analyses inadequate well-control planning, ineffective hydrostatic and valve barriers, and ignition-source management. Recommendations address workover methods for underpressured reservoirs, well-history review and gaps in industry guidance and federal regulation.
- 202321 Dec
KMCO LLC Fatal Fire and Explosion
Investigation of the fatal isobutylene explosion and fire at KMCO’s Crosby facility. Metallurgical testing established pressure-driven brittle fracture of a cast-iron y-strainer. The report examines thermal-expansion hazards, manual versus remote isolation, emergency-response roles and alarm use, identifying weaknesses in hazard evaluation and response that contributed to the incident and its severity.
- 202311 Dec
Foundation Food Group Fatal Chemical Release
Investigation of a fatal liquid nitrogen overflow at Foundation Food Group’s poultry plant. A deformed bubbler tube disabled freezer level control and overflow protection, producing an oxygen-deficient room atmosphere. The report examines design dependencies, missing monitoring and ventilation, emergency preparedness, process safety management and regulatory gaps.
- 2023Dec
Overfill of vapour recovery units
HSE warns that a gasoline overfill exposed dependence between a vapour recovery unit’s process controls and overfill protection, resulting in loss of containment. The notice calls for risk assessment, physical verification, inspection, maintenance and testing of safety functions, with independent safeguards and control-system modifications where required, managed through change procedures.
- 202327 Nov
Failure of proportional valve in saturation chamber control
A proportional valve feedback fault interrupted saturation diving, without injury or equipment damage. Automatic safeguards isolated the line and transferred control to a manual valve. Unauthorised dismantling obscured the origin of potentiometer damage; debris was also found. Lessons address manufacturer-led maintenance, critical spares, training and testing before diving resumes.
- 202321 Nov
EI 158 Fatality Failure to Use Safety
An offshore worker died when surface casing failed during pressure testing supplied by a high-pressure well. The explosion involved pressure release without signs of ignition. BSEE identifies omitted pressure safeguards and deficiencies in planning and change management, and recommends operators consider equipment compatibility checks, gauge training and improved hazard assessment.
- 202314 Nov
Flash Fire from Oxygen Regulator Leads to Burn Injury
A crew member suffered first- and second-degree wrist burns when an oxygen regulator burst during preparations for welding in platform decommissioning. The alert explains oxygen-system ignition hazards and recommends considering brass rather than aluminium fittings, controlled valve opening, contamination prevention, maintenance, training and protective clothing that keeps skin covered.
- 202312 Sep
Finger injury while setting up pipe cutting operation
A crew member’s middle finger was trapped between a scaffold tube and a pipe cutting machine during vertical setup for jumper repair. A defective inlet valve allowed air to energise the machine. The flash discusses omitted manual setup validation, unsafe hand positioning, revised procedures, toolbox talks, operator training and pre-use inspections.
- 202329 Aug
MSF: Air cylinder – high pressure discharge
A breathing apparatus cylinder’s pillar valve broke off while a crew member drained residual pressure before landing it ashore. Nobody was injured. The investigator considered impact from dropping the cylinder responsible. Recommendations address secure handling, slow controlled discharge, valve orientation and PPE; the owner is investigating excess-flow valves.
- 202317 Aug
Engine room fire on LPG carrier Moritz Schulte with loss of 1 life
Investigation of a fatal engine-room fire aboard Moritz Schulte in Antwerp. Pressurised marine gas oil escaped during inadequately isolated fuel-filter cleaning and ignited on an adjacent engine’s hot exhaust. The report examines maintenance arrangements, competence assurance, escape equipment and rescue coordination, including thermal imaging. No recommendations were made following actions already taken.
- 20233 Aug
Near miss with high pressure gas due to incorrect procedures
A crew preparing to pig high-pressure gas mains questioned a valve closure and identified that it would block the intended downstream flow. Work stopped and valves were restored to normal. Review found instructions based on an obsolete drawing; operations remained suspended pending correction, avoiding a compressor trip and possible downstream supply problems.
- 20236 Jul
Intercontinental Terminals Company (ITC) Tank Fire
Investigation of the March 2019 tank-farm fire at ITC’s Deer Park terminal, following a circulation-pump seal failure and butane-enriched naphtha release. The report examines pump maintenance, gas detection, emergency isolation, fire spread, containment failure and regulatory exemptions, with recommendations addressing mechanical integrity, tank-farm design and process safety management.
- 202329 Jun
Watson Grinding Fatal Explosion and Fire
Investigation of the Houston propylene explosion that killed two employees and a nearby resident. It examines a degraded, poorly crimped hose, inconsistent supply isolation and non-functional automated safeguards. Findings address process safety management, change assessment, emergency preparedness and regulatory exclusions; lighting activation is identified as the likely ignition event.
- 202325 May
LyondellBasell La Porte Fatal Chemical Release
This investigation examines the fatal chemical release during plug-valve actuator removal at LyondellBasell’s La Porte complex. Two workers died following exposure to acetic acid and methyl iodide. It compares similar incidents and examines valve design, pressure-retaining components, work procedures, training, isolation and pre-authorisation risk assessment.
- 202316 May
Differential pressure: Dummy choke ejected close to divers
A dummy choke insert was expelled by differential pressure during replacement work near two divers, who remained unharmed. The flash examines absent local venting, misunderstood pressure readings and unclear release expectations. It recommends explicit procedures and risk assessments, isolation training, confirmation of an open local vent and clarification of questionable instructions.
- 20233 May
Near miss: Steam and water released from filter
A mechanic cleaning boiler circulation pump strainers encountered an unexpected steam and water release. The isolation valve had not fully closed; a supervisor subsequently closed it further. Revised procedures specified opening the filter bypass before inlet and outlet isolation, followed by upstream and downstream draining and purging to ensure zero energy.
- 2023May
LPG forklift truck fire risk
This safety alert addresses fires during starting of LPG-powered forklift trucks and similar vehicles. Fuel-system deposits can cause valves to stick, while repeated starting attempts can release unburned gas. It specifies operator precautions and maintenance actions, including stopping further starting attempts, isolating the gas supply and ensuring ventilation.
- 202320 Apr
BSEE: Person injured when safety mechanisms failed
An offshore sandblasting worker sustained head and shoulder injuries when a T-connection detached and a whip check failed. The flash discusses improper cable crimping, slightly corroded baling wire and stresses from horizontal hose positioning. Recommendations address additional securing, fitting orientation, pre-job inspection and depressurisation before valve adjustment where practical.
- 20234 Apr
Cut and bruise to right hand whilst pressure testing
A technician injured his right hand while removing a blanking flange after hydraulic hose pressure testing. Although the panel gauge indicated zero, a check valve trapped residual pressure. The flash recommends a ten-second delay after opening the main pressure valve, a second hose gauge, revised instructions and an updated task risk assessment.
- 202327 Mar
Leak of oil-based mud
A vessel preparing to transfer oil-based mud to shore spilled about 20–25 litres through tank ventilation during hose pressure testing. A deteriorated valve seal prevented full closure. The flash describes deck containment, toolbox communication, valve replacement, monthly manifold-valve cleaning and clearing residual chemicals or mud from transfer lines.
- 202323 Mar
Safety warning issued about the hazards of flexible hose installations
MAIB examines a Finnmaster engine-room fire caused by a flexible fuel hose overheating after an exhaust leak, releasing marine gas oil onto a hot surface. The bulletin discusses hose length, routing, inspection difficulties and unapproved alarm-system modifications, highlighting modification risk assessment, classification requirements and isolation valves.
- 202327 Feb
Near miss: Foreign body in diver’s helmet, resulting in fall of gas pressure
A diver at 18 m experienced reduced breathing gas pressure. Bailout gas did not resolve the problem, but free flow restored suitable pressure. A plastic shard from a broken cleaning pot was found in the helmet regulator. The flash highlights pre-dive checks, cleanliness and the member’s introduction of spray bottles.
- 202317 Feb
Person Injured when Safety Mechanisms Failed
A sandblasting worker on a Gulf of Mexico offshore facility suffered head and shoulder injuries when a T-connection released and a whip check broke. The alert discusses improper crimping, potentially weakened baling wire and hose orientation, recommending improved securing, pre-job assessment, equipment checks and depressurisation when practical.
- 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.
- 202318 Jan
Diving instructor killed – incorrect valve threads
A diving instructor was fatally struck by a valve that detached from a cylinder during a dive. The cylinder’s G3/4 internal thread was incompatible with the valve’s M25x2 external thread. The flash advises members to follow IMCA guidance on diving cylinder and valve thread compatibility.
- 202229 Dec
Husky Energy Superior Refinery Explosion and Fire
Investigation of the Superior refinery explosion during fluid catalytic cracking shutdown. It examines air entering hydrocarbon equipment, missing steam-barrier and purge safeguards, eroded slide valves, procedural and training deficiencies, and brittle vessel fragmentation. Debris punctured an asphalt tank, escalating the event into fire; recommendations address transient-operation safeguards and emergency preparedness.
- 202221 Dec
Kuraray Pasadena Release and Fire
Investigation of an ethylene release and fire during reactor startup at Kuraray’s Pasadena plant, injuring 23 workers. It examines unsafe atmospheric pressure-relief discharge, disabled interlocks, alarm flooding, conflicting operating instructions and restricted flare use. Recommendations address safe discharge design, worker exclusion, operating limits, training and independent process safety assessment.
- 202219 Dec
TPC Port Neches Explosions and Fire
An investigation using AcciMap examines dead-leg management in high-purity butadiene service. Its causal analysis identifies an unimplemented process hazard analysis recommendation and a flushing procedure that was not carried out. It also records gaps in requirements for remotely operated emergency block valves on existing equipment.
- 202213 Dec
Oil tank sight glass push buttons wired open
An engine-room visit identified oil-tank sight-glass push buttons deliberately held open with wire, defeating the gauge’s closing feature. The flash explains that accidental damage to the glass tube could allow tank contents to spill, creating slip and fire hazards and depriving equipment of its intended oil supply.
- 202230 Nov
MAIB: A scalding injury
An engineer aboard a cruise ship suffered severe facial scalding after opening an isolated economiser’s drain valve before cooling was complete. Hot water and steam discharged and deflected upwards from a tundish. The flash highlights discharge-path exposure, caution when opening pressurised drain lines, and controlled valve operation using a correctly sized wheel key.
- 202211 Oct
Philadelphia Energy Solutions (PES) Refinery Fire and Explosions
Investigates the PES refinery fire and explosions following corrosion-induced rupture of an elbow in its hydrofluoric acid alkylation unit. Examines material composition, inspection coverage, vessel failure, unavailable remote isolation and impaired water-spray mitigation. Contrasts successful rapid acid deinventory with failed safeguards and assesses alternative alkylation technologies and regulatory recommendations.
- 20223 Oct
BSEE: Unsecured Pressurised Hoses Result in Hand Injuries
This safety flash summarises two hose incidents during coil tubing operations: valve impact injured a thumb during pressure release, and a failed nitrogen connection caused a whipping hose to injure two workers. Recommendations address glove selection, depressurisation, hose restraint, valve checks, job safety analysis and stop-work authority.
- 20225 Sep
Personal injury – burns from hot engine oil to body and face
An engineer suffered burns when hot fuel sprayed onto his body and face while opening a main-engine fuel oil filter aboard a vessel alongside. The flash identifies inadequate risk assessment, improper compressed-air isolation, omitted pressure checks and draining, and failures to follow procedures. Lessons emphasise thorough assessment, supervision and adherence to instructions.
- 202229 Jul
Loy Lange Box Company Pressure Vessel Explosion
Investigation of a fatal steam-system pressure vessel explosion in St. Louis examines oxygen corrosion, incomplete repairs, water treatment and inspection failures. Metallurgical examination and thickness measurements underpin the findings. The report analyses regulatory oversight and process safety management, while noting that the pressure at rupture could not be determined.
- 20222 Jun
Unsecured Pressurized Hoses Result in Hand Injuries 442
BSEE describes two Gulf of Mexico coiled-tubing incidents involving hose backlash and a failed nitrogen hose fitting, with hand injuries and an additional arm injury. Operators and contractors are advised to consider hose restraint, reduced pressure before valve manipulation, suitable gloves, fuller job safety analyses and stop-work intervention.
- 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.
- 202228 Apr
Two catastrophic engine failures, one resulting in a fire, on board ro-ro passenger ferry Wight Sky
Investigation of Wight Sky’s August and December 2018 engine failures, extended to related fleet failures. It distinguishes lubrication loss from a factory bearing-cap assembly error and examines maintenance records, oil and coolant monitoring, contractor support, delayed declutching and missing engine protection. Effective crew response limited the consequences.
- 202221 Apr
Diver experienced an air flow restriction
A surface-supplied diver experienced restricted air flow at 23msw and the dive was aborted without injury. Investigation identified a needle valve that failed to open properly, with possible overtightening linked to premature equipment fatigue. Actions included valve replacement, revised pre-dive checks and operating procedures, and a team emergency debrief.
- 202228 Feb
UK HSE: Liquid petroleum gas (LPG) leak
This safety flash describes a release of around 15 tonnes of LPG at Fawley refinery, undetected for around four hours. HSE identified excessive pressure for the valve and absent flow-discrepancy detection. Emergency personnel reset the valve. The account stresses maintaining protective layers against major incidents; no fire or injury occurred.
- 202215 Feb
Crewmember burned while draining fluid from flare stack
A worker opened a ball valve to drain a flare stack without switching off its ignitor. Drainage allowed gas to reach the flare and ignite. Flammable liquid subsequently fell onto the worker, causing burns despite the fire-resistant clothing and hard hat being worn.
- 202220 Jan
Subsea explosion resulting in damage to crab potting vessel Galwad-Y-Mor and injuries to crew
Investigation of a seabed bomb explosion during crab-pot recovery by Galwad-Y-Mor, causing vessel damage, flooding and significant crew injuries. The report assesses potting-gear disturbance of likely wartime ordnance, fragment examination and explosive traces, alongside watertight subdivision, crew preparedness, rescue and casualty triage.
- 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.
- 202116 Aug
Drawworks Parking Brake Failure
Repeated drawworks parking brake failures culminated in identification of leaking pneumatic circuit components after earlier repairs and successful tests. One failure allowed the travelling block to descend 5 feet, damaging drill pipe. BSEE recommends considering pressure-based engagement checks, additional indicators, component testing and replacement frequencies, and preventive maintenance of the rig air supply.
- 202121 Jul
Metal Obstructions Lead To Hand Injuries
BSEE describes two hand lacerations involving a metal tag during ball-valve operation and a securing band during transmitter connector work with channel lock pliers. Gloves were absent in one case and insufficient in the other. Recommendations for consideration address hand protection, valve checks, sharp edges, job safety analyses and safety discussions.
- 202116 Jun
Failure of EGS valve stem on dive helmet
A diving helmet’s emergency gas valve handle broke during pre-dive inspection on deck. Laboratory analysis attributed the failure to pitting and chloride-induced stress corrosion cracking. After replacement and testing, the helmet returned to service. The company introduced scheduled dye penetrant testing and identified three further stems with stress-like indications.
- 202123 Apr
Failed Seal on Subsea Safety Valve Causes Leak
A subsea safety-valve seal failure allowed hydrocarbons into hydraulic lines at a Gulf of Mexico production platform, releasing an estimated three to 50 barrels of hydraulic fluid and oil. The alert describes ROV sampling and leak isolation, and recommends considering hydraulic-system monitoring, alarm configuration and pressure management during leaks and platform evacuation.
- 20218 Apr
Flooding and sinking of trawler Ocean Quest
Investigation of Ocean Quest’s loss following uncontrolled engine-room flooding. The source remained undetermined, but shell plating or weld failure beneath the main engine was considered almost certain. Analysis examines hull survey limitations, reduced bilge-pump effectiveness with partly open sea suctions, unusable borrowed pumps and successful crew abandonment following regular drills.