Topic
Human Factors
Interactions between people, tasks, systems and organisational conditions.
Newest 100 Documents
All 1,026 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.
- 202619 Aug
Segregate Pyrotechnics and Verify Flare Type Before Emergency Drills
A worker suffered second-degree burns after mistakenly activating a parachute flare rather than a handheld flare during a fast rescue craft drill. The alert examines mixed storage, inadequate planning and training, and procedural non-adherence, recommending consideration of improved segregation, labelling, task-specific controls and alternatives to offshore pyrotechnic expending.
- 202612 Aug
Improper Use of Hand Tools and Unplanned Deviations from Job Tasks Results in Injuries
Two construction workers sustained facial lacerations during bolt removal: one from an ejected pneumatic rivet-buster piston during troubleshooting, the other from reciprocating-saw kickback after changing tools and removing a face shield. The alert recommends considering pneumatic isolation, manufacturer instructions, job safety analysis updates and stopping work when tasks or protective equipment require reassessment.
- 202615 Jul
Allision of the rigid inflatable boat Peaky Blinder with a navigation beacon with the loss of 2 lives
Investigation of Peaky Blinder’s fatal allision with a navigation beacon in Portsmouth Harbour examines excessive speed, ineffective lookout and alcohol-related impairment. It discusses absent personal flotation devices, recreational boating alcohol regulation and harbour speed enforcement, with recommendations addressing statutory alcohol limits, public awareness and adherence to speed restrictions.
- 202618 Jun
Fall overboard from the crab potting vessel Amadeus (TH7) with the loss of 1 life
Investigation of a fatal fall overboard during manual crab-pot hauling on Amadeus in the North Sea. It examines low bulwark protection, biomechanical demands, almost certain significant fatigue, absent flotation and ineffective recovery arrangements. Findings address deficient safety management and regulatory oversight, with recommendations on fall prevention, handling assessment and work–rest monitoring.
- 202614 May
Worker suffered crush injury while handling unstable steel plates
A worker holding vertically balanced steel plates sustained hand, wrist and finger fractures when a plate toppled, trapping their hand and wrist. The flash examines temporary storage, removed sea fastenings, limited workspace and inadequate task risk assessment, highlighting how local conditions and past experience shaped the work.
- 202626 Mar
Fatal accident to a crew member on board the roll-on/roll-off cargo vessel Laureline
Investigates a crew member’s fatal crushing between a reversing trailer and Laureline’s structure during cargo operations at Purfleet. CCTV review and scene inspection informed analysis of driver–crew communication, danger-zone definitions, training and supervision. The report examines procedural weaknesses, subsequent safety actions and recommendations for an industry vehicle-deck code of practice.
- 202624 Mar
MAIB: Sinking of tug Biter with loss of two lives
This safety flash summarises MAIB findings on Biter’s fatal girting and capsize during passenger-vessel towage off Greenock. It highlights incomplete operational exchanges, inadequate pilot training, speed-related line loading, ineffective gob-rope protection and an open hatch. Recommendations address risk assessments, gob-rope rigging, manoeuvring speeds and tug-master and pilot training.
- 202624 Mar
MSF: High potential near miss during FRC maintenance
During sling replacement aboard a vessel, a fast rescue craft slipped from its davit cradle. Two crew members jumped into the sea and were recovered unharmed. The flash describes inadequate securing, a failed bowsing-line carabiner and gaps in work planning, including missing procedures, risk assessment and permit authorisation.
- 202624 Mar
Person injured when pry bar slipped
A crew member fractured a right-hand knuckle after a pry bar slipped while refitting a dislodged vehicle track. The flash discusses circumstantial pressure from worsening weather, amendments to the job safety analysis and the possibility that impact gloves might have reduced injury severity without preventing it.
- 202617 Mar
Unsafe handling of gas cylinders
A Chief Mate identified unsecured compressed gas cylinders on the quayside before planned gas cutting and welding during vessel maintenance. The flash discusses contractor awareness, perceived time pressure and unavailable securing arrangements, highlighting approved racks, restraint, contractor coordination and crew confidence to stop unsafe 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.
- 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.
- 202612 Feb
Girting and capsize of tug Biter with the loss of two lives while assisting passenger vessel Hebridean Princess
Investigation of Biter’s fatal girting and capsize while assisting Hebridean Princess on the River Clyde. It examines towing speed, bridle loading, gob-rope securing, watertight integrity, operational exchanges and training. The precise reason for gob-rope rendering remained unresolved; post-salvage testing found the towing-hook release mechanism functional.
- 202611 Feb
Collision between the bulk carrier Polesie and the general cargo ship Verity resulting in the sinking of Verity and loss of five lives
Investigation of the German Bight collision between Polesie and Verity, which rapidly sank with five fatalities. It examines incremental collision-avoidance manoeuvres, navigation displays, late vessel traffic service intervention and duplex radio limitations, alongside flooding, search and rescue, and the constraints imposed by absent voyage data recorder evidence.
- 20265 Feb
Collision between the crude oil tanker Apache and the stern trawler Serinah (GH 116)
Investigates the collision of Apache and Serinah in the Firth of Clyde and the trawler’s subsequent flooding and sinking. Examines inadequate avoiding action, watchkeeping competence, navigation equipment, traffic monitoring and assistance after collision. All three fishing crew survived uninjured; recommendations address navigational training and understanding fishing vessel behaviour.
- 2026Feb
CHIRP Superyacht FEEDBACK 11 (February 2026)
Six superyacht reports examine an unpermitted hull repair, a close-quarters encounter, grounding on uncharted coral, fuel-handling failure, hazardous acetone use in a bilge sump and premature anchor release. Commentary addresses reporting culture, collision avoidance, passage planning, fuel purification, respiratory protection limitations and confined-space precautions, emphasising communication and challenges to unsafe decisions.
- 202627 Jan
Human Factors information paper - Critical task analysis
This information paper explains how critical task analysis supports identification and assessment of human error risk in offshore petroleum operations. It describes hierarchical and tabular task analysis, data collection, goal decomposition and plans analysis, then outlines risk assessment and a staged organisational approach to introducing the methodology.
- 2026
CHIRP Maritime FEEDBACK 82 (Spring 2026)
Maritime reports examine solvent use in bilges, navigation audit findings, refused fuel-tank entry, twin-lanyard misuse and obstructed pilot access. Further cases address partial power loss linked to an unannounced software update and pressure over navigation decisions. Commentary emphasises equipment limitations, safe attachment, supplier communication and supportive bridge leadership.
- 202518 Dec
LTI: Leg injury while using hand-held grinder
A worker cutting wood with a hand-held grinder suffered a serious calf injury when the tool slipped, struck the floor and bounced back. The flash discusses prompt power shutdown and medical care, tool suitability, omitted toolbox discussion and perceived time pressure behind choosing a grinder rather than a hand saw.
- 202518 Dec
Man overboard in port: Seaman falls from quay access ladder
A seaman climbing a damaged quay access ladder became distracted by moving mooring lines, lost balance and fell onto the gunwale before entering the water. Recovery was achieved without serious injury. The flash highlights continued use of defective access, concentration, stop-work intervention and consideration of quayside conditions in task planning.
- 202510 Dec
Critical task analysis information paper
Explains how critical task analysis supports identification and management of human error risks in offshore petroleum operations. Describes hierarchical decomposition into goals, operations and plans, followed by tabular error analysis and risk assessment. Outlines stakeholder engagement, piloting, iteration and documentation when introducing the methodology.
- 202510 Dec
Psychosocial risk management guidance note
Guidance for offshore petroleum duty holders on managing psychosocial hazards and meeting health and safety obligations. It explains individual, job and organisational risks, their effects on human performance, assessment methods, and promotion, prevention, intervention and mitigation measures. Periodic review and a practical workload-management example illustrate reducing risk to ALARP.
- 20259 Dec
Human error risk reduction to ALARP information paper
This information paper suggests an ALARP-based approach to human error risk in the Australian offshore petroleum industry. It treats error as a barrier-defeating factor and outlines critical-task identification, error classification, performance-shaping factor analysis and control evaluation, distinguishing prevention from recovery and consequence mitigation.
- 20259 Dec
Human factors in accident investigations information paper
This information paper outlines a human-factors approach to accident investigations in the Australian offshore petroleum industry. It treats human error as a potential control failure mechanism rather than a root cause, recommending cognitive error classification, interviews to identify performance-shaping factors, barrier analysis and targeted corrective actions.
- 20259 Dec
Safety culture information paper
Explains NOPSEMA’s non-mandatory safety culture model, linking executive commitment and behaviour with leadership practices, organisational systems, working environments and safety outcomes. Drawing on Schein’s cultural layers, it uses contrasting fictional petroleum companies to illustrate how shared assumptions shape reporting behaviour and the effectiveness of safety improvement initiatives.
- 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.
- 20254 Dec
Dropped pallet during cargo transfer
A plastic pallet carrying lubricant drums tipped and fell during a barge-to-vessel lift at an anchorage, rupturing drums and spilling oil on deck without injury or structural damage. The flash examines inadequate securing, procedural non-compliance and crew coordination, and describes improved load checks, secondary securing, toolbox meetings and supervision.
- 20254 Dec
Vessel ran aground
A vessel grounded in a narrow channel at low tide during a short voyage, then refloated without damage, injury or pollution. The flash examines shortcomings in passage planning and watchkeeping, including bridge distractions and overconfidence in familiar waters. Lessons emphasise approved passage plans, briefings, tidal knowledge and under-keel clearance.
- 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.
- 202521 Nov
Emergency planning guidance note
Guidance on emergency planning and safety-case requirements for offshore petroleum facilities. It addresses command arrangements, team competence, medical provision, equipment assurance, communications, evacuation analysis and emergency shutdown. It distinguishes regulatory obligations from suggested approaches and explains performance standards, drills, review and management of planning changes.
- 20257 Nov
Watertight door and emergency hatch found open at sea
An offshore audit found engine-room watertight doors and an emergency hatch open at sea, compromising protection against flooding. The flash discusses possible heat-related shortcuts and gaps in crew awareness of closure requirements. It calls for closed barriers at sea, regular training refreshers and proper ventilation rather than opening safety closures.
- 202529 Oct
Hazard identification guidance note
Guidance on systematic hazard identification for offshore petroleum facilities and its integration with formal safety assessment. It compares HAZOP, task analysis, FMEA, what-if and tree-based methods, explaining their limitations. Workforce participation, documented assumptions, justified exclusions and ongoing review support assessment of major accident hazards and wider health and safety risks.
- 202527 Oct
Injury after fall from vertical ladder
A crew member carrying a fire patrol device lost grip while climbing a vertical ladder and suffered a minor eyebrow cut after striking a steel bund. The flash examines inadequate ladder design and routine-task risk awareness, identifying possible ladder extensions, anti-slip paint, carrying aids and pre-task discussions.
- 202525 Sep
Collision between the tender to Isabell Princess of the Sea and the RIB Vega, resulting in one fatality
Investigation of a fatal collision between a yacht tender and the drifting RIB Vega in Göcek harbour. It examines unsafe speed, night visibility, unused chart-plotter information, possible alcohol impairment and unclear command authority. The passenger died from collision injuries and drowning; subsequent actions addressed tender operations, authority and navigation-light compliance.
- 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.
- 202517 Sep
Uncoordinated Emergency Shutdown due to pipe failure
A tanker cargo discharge stopped when a duty AB activated emergency shutdown after observing a minor leak, without coordinating with the cargo control room. Copper tubing had failed through vibration fatigue. The flash describes revised shutdown procedures, coordination training and periodic vibration risk assessments, with tubing dampers or supports under consideration.
- 2025Sep
1 - Big people in lifeboats and lifesaving appliances
Guidance for offshore dutyholders on accommodating increasing worker weight and size in evacuation and rescue arrangements. It explains statistical passenger design-weight calculations, capacity adjustments, seating and restraint suitability, and considerations for other lifesaving appliances and medical equipment. It also addresses verification, interim arrangements and safety-case changes.
- 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.
- 202521 Aug
Avoiding fatigue guidance note
Guidance for offshore petroleum duty holders on preventing and managing workforce fatigue within the regulatory framework. It examines sleep debt, circadian rhythms and interacting organisational factors, outlining layered fatigue risk management through staffing, roster design, sleep opportunities, screening and training. It also addresses handovers, interrupted sleep, incident investigation and monitoring of barrier performance.
- 202521 Aug
Serious injury to a passenger on the sea safari rigid inflatable boat Lundy Explorer
Investigates a passenger’s permanent spinal injury during wave-induced slamming aboard Lundy Explorer at Ilfracombe. Examines forward jockey seating, passenger bracing, safety briefings, sea-condition decisions and regulatory gaps. Records restrictions on forward-seat use and recommends improved operating procedures and risk assessments within a safety management system.
- 202514 Aug
Injury sustained while operating steel lifting magnet
A crew member suffered a cheek cut requiring fifteen stitches when a steel lifting magnet’s spring-loaded lever recoiled during adjustment. The flash also describes an earlier chin injury involving the same magnet. It examines lever accessibility, maintenance gaps and faded warnings, recommending regular inspection, fault reporting and equipment suitability evaluation.
- 202514 Aug
Shore-side crane boom collides with vessel mast
A dock crane boom struck a vessel mast during shipyard lifting, dislodging wind and GPS sensors onto the deck. The flash describes poor visibility, ineffective banksman positioning and crane movement without signals. Discussion actions emphasise banksman roles, clear communication and providing dockyard management with vessel layout and dimensions before operations.
- 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.
- 202531 Jul
Dive chamber procedures and operations
A chamber operator began venting an outer lock while a diver remained inside following surface decompression diving. Recompression and treatment for omitted decompression followed; the diver remained asymptomatic. The flash examines assumptions, poor visibility and missing transfer checks, stressing diver signals and operator and supervisor verification before venting.
- 202531 Jul
Positive – vigilant watch practices
This safety flash highlights a member’s positive observation of bridge watchkeeping during a complex operation close to five fixed offshore platforms. Over three days and nights, officers of the watch and bridge crew refrained from using mobile devices while on bridge duty.
- 20253 Jul
LTI: Hand injury during capstan maintenance
A crew member suffered a serious hand injury while greasing a vessel capstan when rotation trapped his hand between an underside wire clamp and the deck. The flash examines difficult access and grease-gun design, describing grease-point extensions, clamp removal, revised maintenance procedures and wider inspections for line-of-fire hazards.
- 20254 Jun
Injury to thumb during lifting operations
During vessel demobilisation alongside, a crew member injured his thumb when a crane-held load was lowered onto a flatbed trailer while he repositioned a wooden block. The flash identifies unclear signalling and possible perceived pressure, and recommends lift planning, toolbox talks, agreed communication protocols and safe positioning around loads.
- 20254 Jun
LTI: Back injury in Confined Space (Tank Entry)
A worker injured their lower back after losing hand grip while exiting a confined compartment feet-first through a lightening hole during planned maintenance. The flash examines access ergonomics and gaps in risk assessment, describing additional grab handles, possible platforms under investigation and a review of confined-space entry procedures.
- 202516 May
Unintended Cargo collision during lifting operations
During vessel-to-vessel backloading, sudden rolling disrupted cargo positioning and the load struck adjacent cargo on the receiving deck. Limited clearance, inadequate load stabilisation and delayed communication contributed. The flash highlights toolbox talks, assessment of vessel movement risks, improved coordination and readiness to stop work.
- 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.
- 202516 Apr
UK HSE: Risk of collision with offshore installations from attendant vessels
This safety flash summarises five vessel collisions with offshore installations and wind turbines reported in an HSE notice. Cases examine distracted watchkeeping, restricted visibility, dynamic positioning limitations and bridge communication. Recommendations address watchkeeping procedures, bridge resource management, alarm operation, attendant-vessel monitoring and consideration of sailing audits.
- 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.
- 20256 Mar
Person fell in engine room and injured head
An oiler working alone suffered head injuries after a pipe used to reposition a heavy cylinder head slipped, causing him to fall backwards from an unprotected elevated area. The flash highlights underestimated task complexity, familiarity and inadequate lever insertion, and recommends barriers, serious toolbox talks and avoiding lone working where possible.
- 2025Mar
Risk of collision with offshore installations from attendant vessels
HSE safety notice examines five vessel collisions involving offshore installations and wind turbines. Cases highlight distracted watchkeeping, lost situational awareness, environmental conditions and poor bridge communication. Recommended reviews cover watchkeeping instructions, bridge resource management, navigational alarms and vessel monitoring, with consideration of sailing audits to identify operational bad practice.
- 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.
- 202520 Feb
Crew transfer vessel (CTV) drifts onto turbine tower
After a successful personnel transfer, a crew transfer vessel drifted into a turbine structure at 0.5 knots while crew completed administrative tasks. No injuries occurred; paintwork damage was noted. The flash examines situational awareness, bridge instrumentation and inappropriate transfer authorisation, emphasising lookout and consideration of vessel position and conditions.
- 20256 Feb
Confined space entry hot work fatality
A welder died after entering a pipe to check welding in a shipyard. The flash identifies shortcomings in entry restrictions, supervision, communication, procedures and assessment of argon-related risks. Actions included barriers and signage at specified pipe openings, revised restricted-space procedures, and additional inert-gas input to risk assessments and work permits.
- 20256 Feb
MAIB: Vessel cook injured by spillage of burning cooking oil
A cook aboard an offshore support vessel suffered severe burns when wet chemical suppression displaced burning oil from a shallow-sided gyro pan. A faulty thermostat and unsuitable use for deep-frying featured in the incident. Lessons address hazardous work-arounds, regular maintenance, testing overheated appliances and following manufacturers’ guidance.
- 2025Feb
Communication is the key to safer operations — Process Safety Beacon, February 2025
A bulletin examines unclear torque instructions during pipefitting work that led to a hydrogen chloride release and workers falling while escaping. It contrasts equipment manuals with design drawings and promotes clear written instructions, field demonstrations of critical tasks, worksite permit reviews and radio message repeat-back.
- 202523 Jan
Accident to chief engineer on board motor yacht Baton Rouge with loss of 1 life
Investigation of a chief engineer’s fatal electrocution during ventilation damper actuator replacement aboard Baton Rouge in Antigua. It examines work on a live circuit, unused permit arrangements, heat, inadequate monitoring and rescue planning, and conflicting enclosed-space definitions. Management revised its procedures; the report makes no recommendations.
- 2025
CHIRP Maritime FEEDBACK 79 (Summer 2025)
Six confidential maritime reports examine heavy-weather fatalities, navigational audit findings, lifting entanglement, a pilot boarding fall, obstructed firefighting equipment and exposure to residual acid fumes. Commentary connects operational shortcomings with communication, supervision and safety culture, with separate lessons for seafarers, ship managers and regulators.
- 2025
CHIRP Maritime FEEDBACK 80 (Autumn 2025)
This maritime incident digest examines unsafe pilot transfers, an obstructed escape hatch, incorrect antenna labelling, pest infestation and unsafe fumigation, an unmanned survey vessel capsize, and an enclosed-space inspection injury. Commentary emphasises practical design validation, operational limits, crew welfare and confirmed communication between teams.
- 202411 Nov
BSEE: person fell through open hatch
A worker injured his leg and knee after falling through a hatch opening whose damaged cover had been removed. This flash summarises BSEE findings on situational awareness, fall protection and hazard communication, alongside measures operators and contractors should consider, where appropriate, including barricades, safety gates and spotters.
- 202411 Nov
Dropped object – wooden packing block
During pipelaying, a wooden packing block weighing approximately 1 kg travelled with the pipe into the tower, then fell more than 10 m onto a workstation floor without injury. The flash examines inadequate dropped-object barriers and pipe-deflection gaps, recommending suitable barrier design and personnel separation while warning against risk normalisation.
- 20247 Nov
Crush incident on board ro-ro cargo vessel Clipper Pennant with loss of 1 life
Investigates the fatal crushing of a bosun during semi-trailer loading aboard Clipper Pennant in Liverpool. Reconstructions examined restricted driver visibility and trailer positioning. Analysis addresses unsafe corner-stowage workarounds, a walkway inside the vehicle lane, conflicting duties, inadequate risk assessments and ineffective incident learning, with recommendations for coordinated vehicle-deck procedures and driver standards.
- 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.
- 202424 Oct
Grounding and subsequent loss of stern trawler Ocean Maid
Investigation of Ocean Maid’s grounding at Cairnbulg Point and subsequent loss. It examines unattended watchkeeping, reliance on past tracks across two chart plotters, impaired night vision and likely effects of insufficient sleep. The report analyses navigation competence, risk assessment and the prompt abandonment and rescue of all four crew.
- 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.
- 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.
- 20245 Sep
BSEE Safety Alert 489 - Situational Awareness Pre-Job Assessment
An offshore worker injured his leg and knee after falling through an opening on a blowout preventer work platform where a damaged hatch cover had been removed. BSEE recommends operators and contractors consider pre-job hazard checks, communication, suitable fall protection, barricades and continued reassessment of changing surroundings.
- 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.
- 20241 Aug
Capsize and sinking of fishing vessel Angelena
Investigation of Angelena’s capsize and sinking during single-handed catch recovery off Exmouth. It examines excessive suspended net loading, low fuel levels, vessel modifications and absent stability testing. The report also analyses crewing assumptions in risk assessments, stability training and lifesaving arrangements that helped the uninjured skipper survive.
- 2024Aug
CHIRP Superyacht FEEDBACK 7 (August 2024)
Six superyacht reports examine tender lifting-point failure, fouled anchors near a lee shore, an open shell door, a fall during window cleaning and unsafe diving arrangements. Commentary emphasises thorough risk assessment, properly completed work permits, reliable equipment, crew communication and isolation during underwater maintenance.
- 202431 Jul
Load lost from lorry on public road – inadequate securing of cargo
A lorry lost stacked hose cargo on a public road while negotiating a roundabout at low speed. Inadequate securing, unclear instructions and complacency were identified. The flash describes improved transport instructions covering securing materials, strap numbers and checking responsibilities, alongside a yard-team review of human factors.
- 202425 Jul
Grounding and subsequent loss of commercial swim event support vessel Channel Queen
Investigation of Channel Queen’s grounding on the Varvassi wreck during an Isle of Wight relay swim on 20 July 2023. It examines inadequate passage planning, ineffective navigation equipment use, the qualified skipper’s departure and divided attention at the helm. Recommendations address qualified crewing and chart-based passage planning; flooding led to beaching and abandonment.
- 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.
- 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.
- 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.
- 20243 Jun
UK MAIB: Leg injury while mooring
This safety flash recounts a leg injury during unmooring when a messenger line snagged and wound onto a winch drum, tightening around a worker’s leg. It highlights excessive line length and restricted operator visibility, with lessons on keeping clear of moving machinery and maintaining sight and communication during remote operation.
- 20243 Jun
Vessel collided with platform
A vessel waiting on weather collided with an unmanned, unlit platform while using joystick auto heading mode. Nobody was injured and damage was minor. The flash examines distracted watchkeeping, position monitoring and unset navigation alarms, and describes revised DP checklists, watchkeeping analysis and restrictions on non-watchkeeping duties.
- 202422 May
Grounding of roll-on/roll-off passenger ferry Alfred
Investigation of Alfred’s grounding at Swona Island on 5 July 2022, which injured 41 people. The master almost certainly fell asleep while steering close inshore. Analysis examines passage planning, ECDIS use, bridge staffing, fatigue management, emergency response and vehicle securing, alongside shortcomings in audits and surveys.
- 20249 May
AW139 Struck Lamp Post While Taxiing to Park
An AW139 struck a lamp post while taxiing to park at Norwich Airport, damaging all five main rotor blades without injury. The investigation examines misinterpretation of stand markings and attention during manoeuvring. Safety action introduced marshalling for crews not based at Norwich and planned replacement of stand markings.
- 202430 Apr
UK MAIB: Crew member injured by rotating crank handle – LTI
A tug crew member suffered a fractured wrist when a coupling winch’s attached crank handle spun as tensioned barge lines were released. The flash examines failure to remove the handle under the operating procedure, restricted supervisory visibility, dynamic risk assessment and toolbox talks, noting that CCTV could help.
- 202416 Apr
A reminder on watertight doors
A safety walkaround found watertight doors open when they should have been secured. Reviews on other fleet vessels identified routine shortcuts and gaps in crew awareness. The flash explains flood containment, reiterates SOLAS and company closure requirements, and asks how safe working could be made easier.
- 202427 Feb
Crew Transfer Vessel (CTV) hit protruding scaffolding on a supply vessel
A crew transfer vessel struck scaffolding protruding from an anchored offshore supply vessel, damaging a railing without injury. The master underestimated the projection and vessel swing, while repeated transfers were treated as routine. The flash calls for a more comprehensive risk assessment addressing protruding objects and continuous swing.
- 202419 Feb
US BSEE: Confined space entry – tank cleaning
This safety flash summarises two tank-cleaning incidents requiring CPR, including unplanned entry while wearing an outside-use respirator. It reports rushing and non-compliance in the first case and a possible cardiac contribution in the second. BSEE recommends considering entry authorisation, task analysis, ventilation, communication, training and rescue arrangements where appropriate.
- 202412 Feb
High potential: navigation near offshore wind turbines
A chartered survey vessel twice breached a wind turbine safety zone while seeking its closest approach line. The flash examines lost situational awareness, unfamiliarity with vessel handling and shortcomings in bridge procedures. Actions address watchkeeping, survey route planning, shift handovers and crew competency vetting.
- 202422 Jan
Person injured going down ladder
A worker descending a fixed carousel manhole ladder lost his footing and fell approximately 87 cm. His helmet came off and his head struck a steel structure. The flash discusses possible contributions from misjudgement, an unsecured chinstrap and poor lighting, and records lighting improvements and reminders to secure PPE correctly.
- 20249 Jan
Divers lifted off seabed by Clump Weight
During subsea diving, taut wire recovery pulled two divers from the seabed to 18 m above their maximum excursion depth, risking pressure-induced injuries. Both reported well after transfer and tests. The flash identifies communication failures and missing lift planning, and describes revised diver-clearance requirements, repeat-back instructions and stop-work measures.
- 20249 Jan
UK MAIB: Workboat collision with wind turbine platform
A workboat transferring maintenance teams in an offshore wind farm struck a turbine platform after its master became distracted by paperwork. A crewman suffered two broken ribs and the vessel sustained minor damage. Lessons emphasise maintaining a lookout, checking navigation instruments and reviewing administrative demands on vessel crews.
- 2024
CHIRP Annual Digest 2024
This annual compilation brings together anonymised maritime incident reports and commentary on crew welfare, vessel design, engineering, deck work and navigation. Cases examine enclosed-space entry, mooring injuries, pilot ladders, machinery hazards and groundings. Discussion emphasises leadership, communication, work permits, training and lessons for conventional and autonomous vessel operations.
- 2024
CHIRP Maritime FEEDBACK 75 (Summer 2024)
Confidential maritime reports examine commercial pressure over damaged anchors, laundry and cargo fires, machinery and mooring hand injuries, inadequate provisions and a grounding. Commentary addresses escalation of concerns, bridge coordination, laundry practices, dangerous-goods stowage, machinery isolation and guarding, and keeping hands clear during mooring.
- 2024
CHIRP Superyacht FEEDBACK 5 (Winter 2024)
Five superyacht reports examine a night-time tender grounding, suspected lithium-ion battery thermal runaway, swimmers endangered by propulsion start-up, unsecured shipboard appliances and failure to wear a tender kill cord. Commentary addresses passage planning, communication, crew training, appliance securing and proposed kill-cord interlocks, retaining uncertainty about the battery fault.
- 202318 Dec
Failure of personal isolation procedures: Crane became damaged when it was used inappropriately
A crane aboard a vessel in dry dock was damaged when crew attempted to operate it during hydraulic repairs. Personal isolation had been used across several days by multiple people and removed for testing. The flash highlights inadequate risk assessment, the missing permit to work and restrictions on personal isolation.
- 202318 Dec
Line of fire near miss during lifting operations
A banksman narrowly avoided a structure being landed on a vessel’s back deck; an adjacent container was damaged. Inadequately spaced bumper bars allowed load rotation and were wrongly relied upon for personnel protection. The flash discusses exclusion zones, unassessed changes and differences between planned and actual work.
- 202314 Dec
Heavy contact between the high-speed passenger craft Seadogz and a navigation buoy with loss of 1 life
Investigation of Seadogz’s fatal collision with a navigation buoy in Southampton Water. It examines skipper workload and visibility, chart plotter accessibility, passenger seating and handhold protection, lifejacket effectiveness, and operator oversight. Recommendations address passenger protection, inconsistent regulatory guidance and port assessment of high-speed commercial passenger operations.
- 202313 Dec
BSEE Safety Alert 477 - Hazards of Working in Confined Spaces
BSEE describes two tank-cleaning incidents requiring CPR: an unplanned entry to free a vacuum nozzle and illness followed by collapse during exit. The alert examines procedural lapses and rushing in the first case, and recommends operators consider entry planning, communication, ventilation, appropriate respiratory protection, rescue arrangements and current training.
- 20236 Dec
LTI: Fingers injured during fender lifting operation
A crew member sustained severe finger injuries when a polypropylene hauling rope jerked under swell-induced tension during fender lifting. The flash examines hand positioning, inadequate task analysis and failure to stop work as conditions changed. It discusses glove limitations, rope slack and prompt onboard medical care.