Topic
Incident Investigation
Methods and practice of investigating incidents.
Documents
- 202615 May
Preventing sexual harassment in the offshore energy industry guidance note
Guidance for offshore petroleum duty holders on preventing and responding to sexual harassment as a psychosocial hazard. It addresses legal duties, worker consultation, proactive hazard identification, documented risk assessment, work design and leadership. Reporting privacy, investigation arrangements, worker support and review of prevention measures are also discussed.
- 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.
- 202512 Jun
Diving Guidelines - Diving Safety Management Systems and Diving Project Plans
Guidance for preparing diving safety management systems and project-specific diving plans under OPGGS and OEI regulations. It addresses hazard assessment, operational procedures, competence, maintenance, workforce consultation and change management. Emergency provisions include diving bell rescue and evacuation of saturation divers while maintaining pressure, alongside monitoring, investigation and audit requirements.
- 20253 Jun
TS USA Molten Salt Eruption
Investigates the fatal molten-salt eruption at TS USA’s Chattanooga facility on 30 May 2024. Retained water in a plugged roller generated pressure before entering the oxidising bath and producing a steam explosion. Examines drainage hazards, reprocessing procedures, training, protective barriers and failures to share learning from earlier incidents.
- 202327 Nov
Compressed air rather than oxygen supplied to divers
This safety flash describes divers receiving compressed air instead of oxygen through their built-in breathing system, with two decompression illnesses reported. It examines incorrect gas-quad identification, missing oxygen-fraction checks and an analyser coverage gap. Lessons address supplier oversight, technical competence, investigation training and gas-management verification.
- 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.
- 20228 Nov
MAIB: mv Teal Bay mooring fatality
This flash summarises MAIB findings on a fatal mooring-line strike aboard Teal Bay during ship-to-ship grain loading. It examines open fairlead containment, increasing lead angles, insufficient crewing and planning, and delayed medical response. Actions include crew training and planned replacement of open fairleads; remote investigation constrained available evidence.
- 202222 Jun
Capsize and sinking of whelk potter Nicola Faith with loss of 3 lives
Investigation of Nicola Faith’s fatal capsize in Colwyn Bay examines vessel modifications, combined catch and pot loading, and survival arrangements. Stability testing and modelling underpin the conclusion that loading almost certainly caused sudden instability. The report also assesses regulatory gaps, mandatory training, emergency beacons and personal flotation.
- 202130 Jul
Fault in high voltage equipment
A vessel’s portable seismic sparker produced sparks at its -5600V terminals during initial testing. Investigation identified incorrect washers and bolt threading that could prevent full tightening. Training time was reduced and reporting delayed four weeks. Recommendations address competence, risk assessments, stopping work, power isolation and prompt investigation.
- 202023 Nov
BSEE Establishes Goal to Reduce Lifting Incidents by 50%
BSEE sets a goal of reducing lifting incidents by 50% in 2021 on the Outer Continental Shelf. Drawing on reported incident patterns and human-factor findings, the alert recommends that operators and contractors consider improved pre-work planning, better causal data and rigger training, using SEMS methodology to improve lifting safety performance.
- 202025 May
Complex decision making information paper
This information paper explains how offshore petroleum personnel make decisions in complex, changing situations using mental models, pattern matching and satisficing. It discusses cognitive biases and the limitations of prescriptive procedures, proposing scenario-based training, decision aids and investigation approaches that examine why actions made sense at the time.
- 2018Oct
Demystifying Human Factors (IOGP Report 621)
Guidance for incorporating human factors into existing incident investigations, covering preparation, evidence gathering, interviewing, analysis, recommendations and reporting. It emphasises understanding behaviour within organisational conditions, avoiding bias and blame, and developing sustainable improvements. A recurring hypothetical oil-drain example illustrates the approach without prescribing a particular investigation technique.
- 201612 Oct
Collision between the stern trawler Karen and a dived Royal Navy submarine
Investigation of a submerged Royal Navy submarine snagging Karen’s trawling gear in the Irish Sea. It examines mistaken acoustic classification, passive-sonar limitations, passage appraisal, warp and winch behaviour, and the crew’s response. Restricted access to primary evidence limited causal findings; recommendations address submarine procedures, training and fishing-vessel guidance.
- 2016Oct
Recommended Practices for Safety and Health Programs in Construction Download
Construction guidance sets out an integrated safety and health programme built around management leadership, worker participation and proactive hazard assessment. It explains control selection, accessible training, incident investigation and performance monitoring, alongside coordination between contractors and staffing agencies. Programme review and worker feedback support continuing improvement as site conditions change.
- 2016Oct
Safety and Health Programs: Recommended Practices
Non-mandatory recommendations set out an integrated workplace safety and health programme centred on management leadership, worker participation and continuous improvement. They cover proactive hazard assessment, control selection, investigation, accessible training and performance evaluation, with specific arrangements for exchanging hazard information and coordinating contractors and staffing agencies.
- 2015Jan
Work Related Deaths Protocol
This liaison protocol sets out how police, prosecutors and enforcing authorities jointly investigate work-related deaths in England and Wales. It addresses investigative primacy, handovers, reviews, prosecution decisions and communication with bereaved people and coroners. Annexes outline enforcement responsibilities and national and regional liaison committee arrangements.
- 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
Incorrect Flight Recorder Torque Conversions Following Sikorsky S-76C++ Go-Around
This special bulletin examines incorrect flight-recorder torque conversions following a Sikorsky S-76C++ go-around at a private East Sussex landing site. Revised conversions revealed total torque above the maintenance threshold. Calibration supported the revised factors, and the AAIB recommended consolidated, correct conversion documentation for the affected flight data acquisition unit.
- 2014Oct
Consulting workers on health and safety
Approved Code of Practice and guidance explaining employee consultation under the 1977 and 1996 Regulations. Covers union-appointed and elected representatives, direct consultation, information disclosure, paid time and training, workplace inspections, incident examinations and safety committees. Distinguishes statutory duties from guidance and explains protections against detriment.
- 20145 Jun
Macondo Investigation Overview
Overview of the CSB investigation into the Macondo blowout during temporary well abandonment on Deepwater Horizon. It outlines the multi-volume report’s technical, organisational and regulatory scope, highlighting blowout preventer limitations, safety culture and international regulatory comparisons. It also describes evidence gathering, public hearings and obstacles to the investigation.
- 2013Dec
Managing for health and safety
Guidance for organisational leaders and managers explains an iterative Plan, Do, Check, Act approach to health and safety. It combines proportionate risk assessment with worker involvement, competence, supervision and contractor management, then addresses performance monitoring, incident investigation and review to support continuing improvement.
- 2013Jun
Collision between container vessels Hyundai Discovery and ACX Hibiscus
Investigation of a container-ship collision in restricted visibility near the Singapore Strait. It examines watchkeeping, radar and AIS use, emergency manoeuvring, and compliance with collision regulations. Bridge simulation assesses avoiding options, while unavailable evidence limits underlying-cause analysis. Recommendations address training, safety-management arrangements and investigation cooperation.
- 2012Nov
Collision between general cargo vessel Union Moon and ro-ro passenger ferry Stena Feronia
MAIB examines the collision between Union Moon and Stena Feronia in Belfast Lough on 7 March 2012. Analysis addresses alcohol-impaired performance, bridge-team responsibilities, pilotage exemption arrangements and VTS warnings. Simulator reconstruction explores avoidance timing. Both vessels sustained major damage without injuries or pollution; the report discusses procedural and training improvements.
- 2012May
Grounding of container vessel Karin Schepers
Investigation of Karin Schepers’ grounding near Pendeen examines the master falling asleep, fatigue, probable alcohol contribution, absent lookout and unused bridge watch alarm. It analyses refloating decisions, coastguard intervention powers, emergency checklists and safety-management audits. Recovered voyage data recorder information supplied the accident’s complete record; the vessel refloated without damage.
- 2012Apr
2012-001 Investigation of Fatal Fall, West Cameron Block 643, Platform A, Lease OCS-G 02241, 18 April 2011, Gulf of Mexico OCS Region
Investigation of a fatal fall during well abandonment on a Gulf of Mexico platform. Moving a power swivel exposed a deck opening. The report examines tag-line arrangements, obstructed crane visibility, inadequate hazard discussion and fall protection, supervisory oversight and delayed medical evacuation, using interviews, records and an on-platform reenactment.
- 2012Apr
A guide to the Offshore Installations (Safety Representatives and Safety Committees) Regulations 1989
Explains offshore workforce representation under the 1989 Regulations, covering constituencies, nominations, secret ballots and safety committees. It describes representatives’ inspection and incident examination powers, consultation arrangements, access to information, training and paid time off, alongside protections against disadvantage and recommended election procedures.
- 201217 Feb
Report - Montara investigation: Volume three
Third volume of an expert witness investigation into the Montara hydrocarbon release. It reconstructs the operational timeline, charts H1-ST1 integrity during construction, suspension and re-entry, and evaluates barrier acceptance and verification. Technical responses examine corrosion caps, annular seals, cement isolation, change management and opportunities for risk assessment.
- 2012
Engineering a Safer World: Systems Thinking Applied to Safety
A practitioner-focused book explaining safety through systems theory and constraint enforcement rather than component reliability alone. It develops STAMP, STPA hazard analysis and CAST accident analysis, using varied cases and design examples. Guidance addresses human–automation interaction, safety-guided engineering, operational feedback, organisational responsibilities, management of change and safety culture.
- 201130 Dec
Offshore OHS legislative framework information paper
This information paper explains Australia’s performance-based offshore OHS regime, distinguishing operators’ duties from the regulator’s assurance role. It describes safety-case acceptance, sampled inspections of safety-management implementation, and investigation criteria and enforcement outcomes, with responsibility for safe operation remaining with the facility operator.
- 2011Nov
One Incident – Three Beacons! — Process Safety Beacon, November 2011
Using a refinery fire near Sunray, Texas, this bulletin explains how one incident can yield several distinct safety lessons. It encourages reporting incidents and near misses, thorough investigation of root and contributing causes, and applying lessons to other plants. It also marks the Beacon’s tenth anniversary.
- 2009Jun
DOE Human Performance Improvement Handbook, Volume 1
This DOE handbook explains human performance through individual behaviour, workplace conditions and organisational influences. It combines error prevention with layered control assurance, examining cognitive limitations, investigation, operating-experience learning and safety culture. Leadership practices, just culture and performance improvement methods are developed through conceptual models and illustrative accident accounts.
- 2009Jun
DOE Human Performance Improvement Handbook, Volume 2
This handbook presents illustrative human-performance practices for individuals, teams and managers. It covers task preparation, self-checking, procedure use, communication, verification and handover, alongside organisational assessment, incident investigation and learning. Management tools address latent weaknesses, reporting culture and performance indicators. The practices are not requirements and do not guarantee error-free work.
- 200915 May
Underlying causes of offshore incidents
Research analysis of 67 offshore fatality and major-injury incidents from 2004–2008 combines investigation findings with RIDDOR data. It distinguishes direct causes, underlying causes and management failings, highlighting dropped-object impacts, deficient risk assessment, permits and supervision. Comparisons with earlier studies and inspection programmes inform recommendations for targeted inspections and further research.
- 200830 Oct
Pallet lifter failure
A pallet lifter failed during quayside cargo transfer to a vessel, dropping a crane motor without injury. Corrosion had weakened the frame despite previous inspection. The flash examines conflicting load-weight information, missed deterioration and delayed reporting, recommending thorough equipment checks, accurate weight verification and immediate reporting of lifting-equipment failures.
- 2007Jan
BP America (Texas City) Refinery Explosion — Report of the BP Independent Refineries Safety Review Panel (Baker Panel Report)
An independent panel assesses corporate oversight, safety culture and process safety management across BP’s five US refineries, rather than investigating the Texas City accident itself. Interviews, workforce surveys, document examination and sampled technical reviews underpin findings on leadership, competence, hazard analysis, inspection backlogs, performance indicators and incident learning, with recommendations for sustained improvement.
- 2005Sep
Hayes Lemmerz Dust Explosions and Fire — Final Investigation Report
CSB investigates the fatal aluminium dust explosion at Hayes Lemmerz in Huntington, Indiana. The report examines dry-chip processing, dust collection, deflagration propagation and possible ignition sources using laboratory testing and fault-tree analysis. Findings address collector design, housekeeping, maintenance, protective clothing and incident learning, with recommendations for training, procedures and improved explosion protection.
- 2005Feb
CTA Acoustics Dust Explosion and Fire — Final Investigation Report
Investigation of the fatal phenolic-resin dust explosions at CTA’s Kentucky insulation plant examines oven operation, baghouse performance, cleaning practices and elevated dust deposits. Laboratory testing and logic-tree analysis support findings on hazard communication, fire protection and unresolved earlier fires. Recommendations address dust accumulation, training, nonroutine operating procedures and corrective action.
- 2004Jul
Investigating accidents and incidents
An HSE workbook explaining structured investigation of accidents, near misses and other adverse events. It covers information gathering, causal analysis, selection of risk controls and monitored action plans. Worked machinery-injury and occupational-asthma examples accompany reusable forms and checklists, emphasising organisational causes, human factors and feedback into risk assessments.
- 2003Jan
Georgia-Pacific Corp. Hydrogen Sulfide Poisoning — Final Investigation Report
Investigation of fatal hydrogen sulphide exposure at Georgia-Pacific’s Naheola pulp mill in Alabama. Sodium hydrosulphide entered an acid sewer and reacted with sulphuric acid, releasing gas through a manway seal. The report examines reactive-hazard identification, sewer modifications, operating procedures, respiratory protection and emergency decontamination, including secondary exposure of medical responders.
- 2002Jul
Regulating health and safety in the UK offshore oil and gas fields - who does what?
This leaflet explains how HSE, MCA and MAIB divide regulatory and accident investigation responsibilities in UK offshore oil and gas work. It describes overlapping offshore and maritime legislation, coordination between authorities, employer and worker duties, and routes for raising health and safety concerns on ships or installations.
- 1999Apr
Sinking of stern trawler Gaul with loss of 36 lives
Investigation of Gaul’s loss with 36 crew on North Cape Bank in February 1974, using an ROV wreck survey, video mosaics and hydrodynamic model experiments. The report concludes that breaking waves caused a knock-down followed by downflooding through open closures, and recommends reopening the Formal Investigation.
- 1999
Reducing error and influencing behaviour
Guidance on reducing human error through ergonomic design, usable procedures and organisational improvements. It distinguishes errors from violations, examines fatigue, shift handovers and safety culture, and explains human reliability assessment. Eighteen intervention case studies demonstrate practical changes, emphasising workforce participation and controls beyond reliance on individual behaviour.
- 1997
Risk management in a dynamic society: a modelling problem
This conceptual research paper models risk management as control across societal and organisational levels. It examines adaptive behaviour, competing objectives and migration towards safe operating boundaries, contrasting functional analysis with task sequences and causal trees. It argues for hazard-specific control models and explicit assumptions in probabilistic risk analysis.
- 1992
Actions by steamship SS Californian during sinking of passenger cruise ship RMS Titanic
This historical reappraisal examines Californian’s response to Titanic’s distress signals through testimony, log records, positional analysis and atmospheric optics. The investigators agree that proper action was not taken but differ over vessel separation. It assesses communication with the Master, wireless readiness and the disputed possibility of rescuing survivors.
- Undated
Capsize and sinking of creeler Kirsteen Anne with loss of 2 lives
MAIB investigated Kirsteen Anne’s unwitnessed capsize after she failed to return from fishing with two crew. Examination and an inclining experiment linked poor stability to vessel modifications, fishing gear weight and bilge water. Recommendations addressed stability standards for vessels under 15 m, risk assessment and fishermen’s awareness.
- Undated
Capsize and sinking of scallop dredger Solway Harvester with loss of 7 lives
Investigation of Solway Harvester’s capsize and sinking south-east of the Isle of Man, with seven crew drowned. Fish-room flooding reduced stability, while heavy rolling shifted scallops and gear. Wreck examination, interviews and model tests supported the findings, including defective bilge arrangements; MAIB rejected an alternative dry-capsize theory.
- Undated
CAST Handbook: How to Learn More from Incidents and Accidents
This handbook teaches CAST, a systems-theory method for analysing accidents without assigning blame. It explains control-structure modelling, controller responsibilities, feedback, human decision contexts and systemic weaknesses. Chemical-plant, workplace and social-system cases illustrate the method, alongside guidance on recommendations, organisational adoption and checking whether improvements are effective.
- Undated
Collision, or close-quarter situation, between trawler Ocean Hound and unknown vessel resulting in trawler capsizing with loss of 5 lives
Investigation of Ocean Hound’s loss and five crew deaths in the Dover Strait examines radar recordings, stopped clocks and underwater wreck surveys. It identifies probable close-quarter interaction causing capsize, with physical contact uncertain, followed by probable collision and sinking. Recommendations address vessel identification, reporting, lookout and practical demonstration of emergency escapes.
- Undated
Creating and Managing a Healthy and Safe Workplace
Employer guidance on organising workplace health and safety under British Columbia requirements. It explains responsibilities, hazard identification, risk assessment and the hierarchy of controls, alongside programme design, inspections, written procedures, training and supervision. Further sections address incident investigations, performance indicators, joint committees, protective equipment and location-specific first aid arrangements.
- Undated
Equinor – Mongstad – investigation of personal injury and steam escape
Investigates a steam release during drainage of boiler low points at Mongstad. An operator escaping the steam fell or slid about four–five metres, sustaining minor torso injuries and a sprained ankle. HTO and Five Whys analysis identified shortcomings in risk assessment, hose securing, work planning and information transfer following a personnel change.
- Undated
Esso – Slagentangen – investigation of naphtha leak
Investigation of a naphtha leak at Esso’s Slagentangen refinery attributes pipe perforation to corrosion under insulation and missing inspection coverage. It examines risk-based inspection, shutdown decisions, gas detection, possible benzene exposure and emergency response shortcomings. Drainage contained the release without discharge to the natural environment.
- Undated
Memoranda of Understanding with the Maritime & Coastguard Agency (MCA)
This memorandum sets out collaboration between HSE, MCA and MAIB where enforcement and accident investigation responsibilities overlap at maritime interfaces. It addresses jurisdiction, independent parallel investigations, regulatory coordination, information sharing, funding and periodic review, while distinguishing safety investigation from criminal enforcement.
- Undated
Memorandum of Understanding
This memorandum sets out how CQC, HSE and local authorities allocate regulatory responsibilities for health and adult social care in England. It addresses investigation primacy, exceptional allocation criteria, joint working, incident notifications and intelligence sharing, with operational escalation arrangements and safeguards for handling personal data.
- Undated
NASA Human Factors Handbook (NASAHFACS)
This handbook explains NASA’s human-factors classification framework for mishap investigation. It sets out evidence gathering, checklist-based coding, impact weighting and graphical analysis for tracking and trending. Taxonomy definitions distinguish acts, preconditions, supervision and organisational influences, with guidance on investigator training and protection of sensitive information.
- Undated
Norske Shell - Nyhamna - Investigation following incidents involving falling objects
An investigation reviews follow-up of falling-object incidents during Shell’s Nyhamna expansion project. It examines company investigation requirements, fall-energy classification, work permits and sharing of lessons. Case analyses include scaffolding components and a concrete hose. Improvement points concern coordinated procedures and underlying-cause analysis; no regulatory non-conformities were detected.
- Undated
Odfjell Drilling – Deepsea Nordkapp – investigation of a lifting incident resulting in personal injury
Havtil investigates a logging-tool lift on Deepsea Nordkapp in which a swaying load struck a slinger, causing serious injuries. Using STEP and HTO analysis, the report examines rigging, changes to the lifting plan, congested decks, competence, communication and supervision, alongside weaknesses in organisational follow-up and emergency response.
- Undated
Sierra Chemical Co. High Explosives Accident — Sierra Chemical Co. Final Report
Investigates two explosions at Sierra Chemical’s Nevada explosives plant that killed four workers and injured six. The report favours mixer startup against solidified explosives but retains alternative initiating scenarios. Physical, seismic and metallurgical analyses support the reconstruction, while findings address deficient hazard analysis, procedures, training, change management and building separation.
- Undated
Snagging, capsize and sinking scallop dredger Pescado with loss of 6 lives
An inspector’s inquiry examines Pescado’s loss with six crew, probably between 25 and 28 February 1991 off Dodman Point. It reconstructs excessive heel during recovery of snagged scallop gear and subsequent downflooding. Underwater surveys, wreck examinations and inclining tests inform analysis of stability, winch arrangements, crew competence and life-saving deficiencies.