Topic
Leadership and Safety Culture
Organisational leadership, culture and behaviour affecting safety.
Newest 100 Documents
All 181 in search- 202628 Jul
Man overboard from the bulk carrier World Prize with the loss of 1 life
This investigation examines a bosun’s fatal fall into the sea during combination-ladder rigging on World Prize. It analyses normalised unsafe practices, ineffective supervision, permit compliance, incompatible flotation and harness equipment, and radio shortages. Pilot-boat recovery capability and training gaps are examined alongside subsequent corrective actions; no recommendations were made.
- 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.
- 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.
- 202622 Jan
Some positive findings and good practices
This flash presents four positive marine safety observations: thorough safety-zone entry checks on a PSV, a fabricated mesh guard protecting an open mud-tank hatch during ventilation, simulator-based officer training in Papua New Guinea, and crew-led deck upkeep. It reinforces procedural discipline, hatch protection, competence development and maintenance beyond dry-dock schedules.
- 2026Jan
Near-misses predict future incidents — Process Safety Beacon, January 2026
This bulletin explains how near-misses can reveal weaknesses in process safety systems before serious incidents occur. It places them within Tier 3 process safety metrics and encourages personnel to recognise and report events, understand company definitions, and ask about learning. Collected reports should be analysed for potentially serious trends.
- 2026Jan
The Offshore Workforce Engagement Inspection Guide
An inspection guide for assessing offshore dutyholders’ workforce engagement arrangements. It examines elected safety representatives, constituencies, committee meetings, consultation, training and paid time for representative functions. Pre-visit document requests and an inspection question set support compliance assessment, with enforcement expectations and guidance on recording performance scores.
- 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.
- 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
Positive – Enhancing safety communication through digital monitors
This positive safety flash describes digital monitors installed across a member’s vessels and offices to provide continuous access to lessons, policies and HSE updates in local languages. It highlights improved awareness and engagement, multilingual inclusion, stronger safety culture and reduced dependence on printed materials.
- 2025Dec
CHIRP Superyacht FEEDBACK 8 (December 2025)
Superyacht incident reports examine a failed mooring attachment, captain harassment, generator starter battery explosions, collision at anchor, unsafe pilot boarding arrangements, unprotected work aloft and defective life rafts. Commentary discusses battery capacity and ventilation, engineering handovers, equipment servicing and testing, reporting concerns and organisational safety culture.
- 202525 Nov
Safety management system guidance note
Guidance on integrating safety management systems with the offshore petroleum safety-case regime. It addresses control effectiveness, workforce competence, work authorisation, change management and continual improvement. Performance standards, monitoring and review underpin assurance, alongside organisational commitment and management of both major accident and occupational risks, including psychosocial hazards.
- 20257 Nov
Involving the workforce guidance note
Guidance on involving workers in safety-case development, revision and implementation. It addresses participation in formal safety assessments, access to information, consultation records and consideration of feedback. Management commitment, representative structures, dedicated time, cooperation and relevant training underpin the approaches described, with mandatory requirements distinguished from recommendations.
- 2025Nov
CHIRP Maritime FEEDBACK 81
Six confidential maritime reports examine a pilot’s fall, unsafe ladder rigging, illegal waste disposal, congested harbour operations involving an uncrewed vessel, a yacht–ferry close-quarters encounter and management intimidation. Commentary discusses transfer procedures, collision avoidance, competence assurance, reporting protections and the influence of leadership on safety and environmental compliance.
- 202527 Oct
LTI: serious injury to thumb when pipe fell during maintenance
A vessel engineer sustained partial thumb amputation when a grey water pipe fell about 1.4 m during dismantling, trapping his thumb against a supporting clamp plate. The flash examines inadequate securing and hand positioning, recommending primary and secondary retention and a workplace culture that enables staff to challenge unsafe practices.
- 202527 Oct
On a more positive note…
Fleet visits identified positive safety practices, including an engaging bridge toolbox talk reinforcing stop-work authority before entry into a 500m zone. The flash highlights well-organised inspection and maintenance of life-saving equipment, advance preparation of firefighting clothing and boots, and the importance of regular drills and crew training for emergency readiness.
- 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.
- 20254 Sep
BSEE: Electromagnetic lifting device dropped steel plate
This safety flash summarises a BSEE incident in which a steel plate detached from a worn magnetic lifting device, fell approximately 1.2 m and injured two workers’ feet. It discusses inadequate task hazard analysis and stop-work culture, alongside recommendations for inspections, load testing, power stability and electromagnetic lifter operating procedures.
- 2025Jul
CHIRP Superyacht FEEDBACK 10
Six superyacht reports examine dismissed safety concerns, inconsistent fall protection, unsafe pilot boarding, crew abandonment, a mooring-line injury and chemical burns. Commentary addresses leadership, reporting protection, procedural compliance and task risk assessment. An appended flag-state flyer reinforces safe working at height, equipment training and intervention in unsafe work.
- 202518 Jun
Workplace safety and consultation arrangements guidance note
Guidance on workforce consultation and representation at offshore petroleum facilities distinguishes statutory duties from suggested practice. It explains designated work group formation, representative selection, training and support, committee membership and meetings, information-access restrictions and dispute arrangements. An appendix sets out representative election procedures, including secret ballots and counting.
- 20256 Jun
BSEE Safety Alert 500 - Dropped Steel Plate Due to Defective Lifting Device and Inadequate Hazard Analysis
A steel plate released from a worn magnetic lifter during drilling operations, falling approximately 47 inches onto two workers’ left feet. The alert identifies inadequate task hazard analysis and reluctance to stop work. Recommendations address lifting-device inspection, functional testing, safety communication, and electromagnet power stability and duty-cycle limits.
- 2025Apr
CHIRP Superyacht FEEDBACK 9 (April 2025)
This superyacht incident digest examines a post-dry-dock fire, unsuitable crew accommodation during repairs, drug use, inadequate provision for working aloft, a falling crane hook, fatigued anchoring and unrecognised enclosed spaces. Commentary addresses safety culture, equipment readiness, familiarisation, design feedback and atmospheric testing.
- 20256 Feb
MAIB: Step-ladder failure (LTI)
A crew member fell when a folding stepladder’s top-step support welds failed, sustaining back and head injuries. MAIB considered pre-existing damage almost certain; the ladder was not overloaded. The flash stresses thorough pre-use inspection, equipment upkeep and a just culture supporting honest incident reporting.
- 2025Feb
Process safety leadership findings of Energy Division inspection programme
HSE reports findings from inspections of UKCS production operators’ process safety leadership, using a consistent framework based on the COMAH leadership intervention tool. It examines leadership competence, contractor assurance, cumulative risk, performance indicators and incident learning, identifying weaknesses alongside good practice and recommendations for duty holders.
- 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.
- 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.
- 202427 Sep
Fall from height on bulk carrier Equinox Seas with loss of 1 life
This investigation examines a fitter’s fatal fall of approximately 10 m through an engine room ventilation trunk aboard Equinox Seas during shipyard maintenance. It identifies inadequate barriers, unassessed fan-removal risks and poor safety coordination, and discusses permit systems, hazard communication and improvements to ship repair safety management.
- 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.
- 2024May
CHIRP Superyacht FEEDBACK 6 (Summer 2024)
This superyacht incident digest examines watertight door failures, a starting battery explosion, a galley fire, unprotected window cleaning and steering loss. Commentary addresses alarm visibility, towing checks, battery maintenance, heat lamp safeguards, crew numbers and the independence of the designated person ashore.
- 202427 Feb
UK HSE: Crane boom collapse
This safety flash describes a crane boom collapse during preparations to recover a faulty submersible pump from an offshore rig. Debris struck a supply vessel and a snagged cement hose ruptured. The investigation identified an unchecked, incorrectly set limit switch, overridden joystick safety mechanisms and defective safety management. Nobody was injured.
- 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 74 (Spring 2024)
This maritime digest examines tug and barge safety, dry-ice asphyxiation, leaking bunker connections, sulphur-emission non-compliance, a fall during mast work, lift-maintenance hazards and open cargo hatches at sea. Commentary addresses leadership, familiarisation, ventilation, permits to work and verified isolation, alongside design shortcomings and protection for confidential reporters.
- 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 Maritime FEEDBACK 76 (Autumn 2024)
This maritime digest examines unauthorised enclosed-space entry, tug propulsion failure during LNG berthing, suspected officer fatigue, rotating-shaft hazards, inadequate provisions, deficient dynamic-positioning capability and departure in strong winds. Case commentary contrasts effective teamwork and stop-work intervention with commercial pressure and weak safety culture, highlighting entry permits, towing configuration and position-reference requirements.
- 20236 Dec
Didion Milling Company Explosion and Fire
CSB investigates fatal combustible corn dust explosions at Didion’s Cambria mill. It examines propagation through interconnected dust collectors and pneumatic conveying systems, secondary explosions and building collapses. Comparative mill teardown, dust testing and explosion modelling support analysis of deficient safeguards, change management, housekeeping, emergency preparedness and regulatory oversight.
- 202330 Nov
Grounding of general cargo vessel BBC Marmara
Investigation of BBC Marmara’s grounding at Eilean Trodday examines a sleeping watch officer, alcohol consumption, absent lookout and disabled bridge watch alarm. It analyses electronic passage planning, ineffective shipboard management and falsified records, alongside distracted coastguard monitoring. Recommendations address crew resources and coastguard cognitive performance.
- 202313 Nov
Positive: Master stopped unsafe fuel transfer whilst vessel alongside rig
A supply vessel halted fuel transfer after its watch officer spotted welding on an adjacent semi-submersible rig. The flash highlights prompt bridge intervention, reporting and positive recognition by rig management. It identifies missing communication about hot work despite mandatory confirmation of simultaneous operations through the Safety Zone checklist.
- 202316 Oct
Job stopped safely: safe working load limits exceeded
During practical rigger assessment, a student challenged the suitability of machined eye-nuts for a four-leg chain bridle. Research confirmed that the fittings permitted only in-line lifts, while the proposed angled arrangement would exceed their safe working load. Work stopped and training continued with another load, highlighting questioning and rigging-plan verification.
- 20238 Sep
Collision between cargo vessel Scot Carrier and split hopper barge Karin Høj with loss of 2 lives
Investigation of Scot Carrier’s collision with Karin Høj in the Baltic Sea, followed by the barge’s capsize, its master’s death and the mate’s presumed death. It examines distracted watchkeeping, alcohol consumption, absent lookouts, disabled navigation warnings, rescue delays and weaknesses in company oversight, while acknowledging uncertainty about the barge crew’s actions.
- 202315 Aug
LTI – Person fractured pelvis in a fall from a ladder
A crew member fractured his pelvis after slipping from a temporary cargo-hold access ladder aboard a cargo vessel. The flash examines blocked permanent access, an unprotected platform edge, absent risk assessment and change management, and unchallenged subcontractor standards. Actions address contractor assurance, supervision, stop-work authority and safe access.
- 2023Jan
CHIRP Superyacht FEEDBACK 1 (January 2023)
This first superyacht incident digest examines backstay entrapment, tender grounding, unfamiliar steering controls, unsafe recovery from the water, an uncontrolled anchor chain and a fatal jet-ski collision. Commentary addresses communication, equipment familiarisation, control testing and the pressures that undermine captains’ safety decisions, alongside crew welfare and medical support.
- 2023
CHIRP Annual Digest 2023
An annual compilation of confidential maritime incident reports and analytical articles covering shipping, commercial fishing, ports and superyachts. Case commentaries examine navigation, mooring, lifting, equipment failures and enclosed-space entry. Wider discussions address safety culture, communication, seafarer wellbeing and fatigue, including an indicative watchkeeper fatigue assessment tool.
- 2023
CHIRP Maritime FEEDBACK 70 (Spring 2023)
This maritime incident digest examines single points of safety failure through reports of grounding, steering loss, unsafe fendering, towing difficulties, coercion, obstructed access, collision, maintenance injury, lifting failure and battery fire. Commentary addresses bridge teamwork, workload, isolation, inspection access and emergency arrangements, with practical lessons for vessel crews and managers.
- 2023
CHIRP Maritime FEEDBACK 71 (Summer 2023)
This maritime digest examines engine defects, misleading master–pilot exchanges, language barriers, a power shutdown, a yacht collision and repeated falls from a paint raft. Commentary addresses commercial pressure, communication and supervision. A separate article describes automated tank cleaning with high-pressure spinning nozzles and remote drone inspections to reduce enclosed-space entry.
- 2023
CHIRP Superyacht FEEDBACK 2 (Spring 2023)
Six superyacht reports examine authority gradients, guest distractions and safety culture through a deck slip, navigational near misses, tender lifting failure, towing capsize and lithium-ion battery fire. Commentary discusses constructive challenge, safe access, inspection limitations, lifejackets, emergency communications and fire response, contrasting weak practices with effective crew action.
- 2023
CHIRP Superyacht FEEDBACK 4 (Autumn 2023)
This superyacht digest analyses an allergic reaction, faulty gangway installation, a dive-vessel capsize, berth-departure contact, mooring injuries and grounding followed by dismissal of a reporting watchkeeper. Commentary examines equipment certification, stability testing, medical preparedness, line-handling teamwork, passage planning and constructive challenges to unsafe decisions.
- 2022Dec
CHIRP Maritime FEEDBACK 69
This maritime digest examines unsafe pilot boarding arrangements, helm execution, substandard ship conditions, collision avoidance, a crushed mooring launch and yacht grounding. Commentary emphasises closed-loop communication, challenging unsafe directions and port coordination. A separate article explores links between fishing crews’ working conditions, labour exploitation and safety.
- 202230 Nov
LTI: person suffered serious crush injuries
An offshore drilling assistant suffered serious crush injuries after leaning between guard railings and becoming trapped between a compensator carriage and rooster box. The flash identifies shortcomings in supervision, procedures, hazard assessment, communication and application of previous lessons, and highlights stop-work intervention and respect for safety barriers.
- 202217 Oct
Maritime Professional Council Report on Kind Leadership 17.10.2022
Interview-based research for the Maritime Professional Council examines maritime leadership training at sea and ashore. Respondents question the adequacy of technically focused STCW and HELM provision and advocate continuing professional development, ethical leadership and staff empowerment. The report discusses trust, long-term cultural change and the commercial value of investing in people.
- 20225 Sep
Chemical burns to body
A recently joined vessel engineer suffered a severe chemical burn while decanting carbon remover for purifier maintenance. Posted instructions were not followed and chemical PPE was not worn; a less hazardous alternative was available. Lessons emphasise comprehensive familiarisation, supervised induction, competence assessment and confidence to stop unsafe work.
- 2022Jun
CHIRP Maritime FEEDBACK 67
Maritime incident reports examine risk acceptance through undocking damage, unsafe access over timber cargo, power and detection failures, collisions, cargo-control distraction, grounding, sinking and boiler repair. Commentary addresses testing, isolation, familiarisation and challenge culture. Additional material describes tug-use training and a pilot-boarding safety checklist.
- 202228 Apr
Reducing incidents through increasing training and supervision of Short Service Employees
BSEE highlights incidents and inspection findings involving short-service employees in offshore oil and gas work. Examples include maintenance and rig-floor injuries and unfamiliarity with safety-system testing. Operators are asked to consider hands-on training, competency assessment, qualified mentoring, limits on short-service employee proportions and oversight of workload and high-risk assignments.
- 2022
CHIRP Annual Digest 2022
A compilation of maritime cases published during 2022, with commentary and supporting insight articles. Reports examine navigation, pilot boarding, mooring, towing, engineering maintenance and working conditions. Discussions address communication, bridge-team challenge, pressurised equipment, harness arrangements, risk assessment, permits and training, alongside examples of unsafe practice and effective intervention.
- 20212 Dec
Crew member stopped unsafe cargo operations
A Second Officer stopped third-party dock-to-vessel cargo lifting after observing an uncoloured wire set and a metal cargo box without valid certification marks. Requested assurance was not provided, so the cargo remained on the quay and was quarantined. The flash highlights stop-work authority, knowledge of colour coding and equipment checks before lifting.
- 202128 Oct
NTSB: The sinking of the El Faro – an illustrated digest
This safety flash summarises an NTSB illustrated digest on El Faro’s fatal sinking during a hurricane in 2015. It highlights command decisions, outdated weather information, ineffective bridge resource management, flooding and propulsion loss, alongside recommendations addressing training, watertight integrity, machinery capability and lifeboat arrangements.
- 20211 Oct
MAIB: Crush fatality during lifting operations
This safety flash summarises MAIB findings on a fatal crushing aboard Cimbris during hatch cover lifting. It highlights restricted operator visibility, the absence of a lookout, inadequate planning and supervision, and poor communication. Company actions included mandatory safety sentries, reviewed procedures and an instruction card defining lookout duties.
- 202124 Sep
AB Specialty Silicones, LLC
Investigation of a fatal hydrogen explosion during silicone-emulsion batch manufacture in Waukegan, Illinois. Reactivity experiments linked unintended potassium hydroxide addition to hydrogen generation. The report examines similar chemical drums, atmospheric batch tanks, ventilation, failed detector trials, evacuation preparedness and procedural checks, alongside process safety culture and regulatory gaps for reactive chemicals.
- 202122 Sep
Crush incident on general cargo vessel Cimbris with loss of 1 life
MAIB investigates a stevedore’s fatal crushing during hatch-cover movement aboard Cimbris at Antwerp Bulk Terminal. The report examines restricted crane-operator visibility, the absence of a banksman, lifting arrangements and ship–shore coordination. It identifies weak safety cultures and records procedural changes and recommendations for the vessel manager and port labour federation.
- 202122 Sep
Stuck emergency hatch freed
An onboard inspection found a rusted emergency escape hatch that could not be opened. The flash identifies poor maintenance culture, neglected safety responsibility and crew unfamiliarity with the hatch’s importance. Actions include keeping escape routes unobstructed, adding hatch inspections to planned maintenance and maintaining greased hinges.
- 202113 Jun
Industry safety improvement initiatives
This interim research report summarises an online survey of Australian offshore oil and gas operators’ safety improvement initiatives. It examines safety indicators, personal and process safety training, leadership coaching, culture perception surveys and improvement strategies. Findings are presented descriptively, with open responses summarised by word frequency and further qualitative research planned.
- 202113 Jun
Safety improvement initiatives in the Australian offshore petroleum industry
Descriptive results from a 2017 duty-holder survey examine personal and process safety indicators, training, leadership, culture and error risk management initiatives. Analysis includes 32 responses, with selected comparisons against 2012 findings. The report presents anonymised aggregate data and verbatim free-text responses without interpretive commentary.
- 202125 May
Crush incident during transfer from workboat Beinn Na Caillich to a feed barge with loss of 1 life
Investigation of a fatal transfer at Ardintoul fish farm, where a worker was crushed between a moving workboat and a feed barge ladder, then drowned after slipping out of his lifejacket. The report examines transfer planning and supervision, crotch straps, recovery preparedness and marine safety management, recommending fleet standards and management expertise.
- 202111 May
Crush incident on scallop dredger Olivia Jean with loss of 1 life
Investigates a fatal head injury aboard scallop dredger Olivia Jean during attempts to free snagged dredge gear. The engineer was probably struck by a towing bar swinging inboard. Analysis examines deck supervision, restricted winch-operator visibility, language barriers, training, risk reassessment and weak safety management, alongside subsequent actions and recommendations.
- 202119 Feb
MAIB: Fatal accident during cargo operations on Karina C
This flash summarises MAIB findings on a fatal crushing aboard Karina C involving a moving gantry crane and hatch covers. It highlights inadequate supervision, poor communication, weak safety culture and unenforced alcohol policy. Alcohol probably impaired judgement; tiredness might also have influenced actions. Reporting followed postmortem findings and CCTV examination.
- 20215 Jan
Stop work authority enforced – unsafe conditions, no appropriate lifting gear available
A master cancelled a planned aviation fuel tank collection after finding the platform landing unsuitable for an AHTS vessel and appropriate heavy-lift gear unavailable. The flash highlights stakeholder communication, leadership by example and crew authority to stop operations when risks cannot be controlled to a reasonably practicable level.
- 202010 Dec
Entry to enclosed space on fishing vessel Sunbeam with loss of 1 life
Investigates a fatal tank entry aboard Sunbeam in Fraserburgh. Leaking refrigerant from corroded evaporator tubes displaced air in a refrigerated salt water tank. The report examines inadequate repairs, non-gastight isolation valves, normalised unsafe entry, absent atmospheric precautions, rescue arrangements and gaps in machinery survey oversight.
- 20209 Oct
Positive: Parted mooring lines spotted before damage could occur
Crew working on a barge noticed another barge’s unusual position at an anchorage and suspected a parted mooring line. A company tug confirmed the damage and the line was replaced. Follow-up actions recognised the crew’s responsibility and arranged regular checks of laid-up barges, particularly before forecast high winds.
- 202014 Aug
Positive: STOP WORK by Master challenging Sailing Order
A platform supply vessel Master challenged sailing orders that conflicted with local requirements for loading radioactive cargo last and dispatching it first. After initial rejection by client logistics, escalation secured company management support. The flash highlights stop-work authority and subsequent collaboration to change the sailing order.
- 202031 Jul
Safety performance in the offshore renewable energy industry
An IMCA safety flash relays HSE concerns about stalled or potentially declining safety performance in offshore renewable energy. It highlights statutory equipment inspections, training and supervision for newcomers, performance monitoring, realistic scheduling, tested emergency arrangements, fatigue monitoring, and reporting and investigation to prevent recurrence.
- 202013 Jul
And finishing on a positive note: A CPR success story – “we saved a life that day”
A crew member survived repeated cardiac arrests following immediate CPR, medic intervention and further treatment before medical air transport. He returned home after three days in hospital. The flash highlights coordinated first-aid and search-and-rescue responses, leadership and preparedness, and encourages additional basic CPR training.
- 202013 Jul
MOB fatality: Person fell between vessel and jetty
This flash summarises MAIB findings on the fatal crushing of Cherry Sand’s Master during self-mooring at Rosyth. He attempted to step ashore before the dredger was alongside. It highlights hazardous transfer practices, absent linesmen and audit shortcomings, alongside recommendations concerning self-mooring guidance and fleetwide procedures.
- 202012 Jun
Near miss/positive: Crew exercised stop work on new gangway
Following an initial transfer test, a captain stopped use of a newly installed gangway after identifying a trip hazard and minor hydraulic leak. Further inspection revealed cracks in welding seams. The flash highlights pre-use inspection, stop-work authority without reprisal, and quarantine of unsafe equipment pending corrective action.
- 202010 Jun
Accident on the stern ramp of the ro-ro freight ferry Seatruck Progress with loss of 1 life
Investigates a third officer’s fatal injury during trailer discharge from Seatruck Progress at Liverpool. Analysis examines obstructed driver visibility, mobile telephone distraction, ineffective warnings and absent pedestrian segregation. Reconstruction and CCTV review inform findings on ship–shore traffic control, generic risk assessments, procedures and safety culture.
- 202021 May
Perception surveys information paper
This information paper examines the limitations of perception surveys for assessing safety culture and predicting safety outcomes in the Australian offshore petroleum industry. It discusses subjective responses, Likert-scale analysis and correlation versus causation, and explains how surveys may contribute to triangulated cultural analysis using observations, interviews and focus groups.
- 202021 May
Personnel resourcing information paper
This information paper examines how personnel resourcing affects human reliability, particularly through fatigue and time pressure. It discusses emergency response staffing, maintenance scheduling and independent checks, and supervisory workload. Drawing on SPAR-H, it outlines approaches organisations may consider to reduce error and support effective risk management.
- 201917 Sep
Fatal fall from height on-board Seatruck Pace in Liverpool in December 2018
A crewman preparing to paint a ramp hatch cover on Seatruck Pace died after falling 4.5 metres through the hatch. He had crossed a temporary safety barrier for undetermined reasons. The flash discusses risk tolerance, procedural adherence and owners’ actions on barriers, work permits, harness records, training and safety culture.
- 201923 Aug
LTI – Fall from height
A subcontracted service engineer returned to a vessel mast to retrieve tools without fall protection. During final radar testing, the rotating antenna struck him, causing a fall onto a lifeboat roof and multiple fractures. The flash highlights communication failures, subcontractor oversight, job preparation and safety culture.
- 20192 Jul
Fall from height on ro-ro freight vessel Seatruck Pace with loss of 1 life
This investigation examines an assistant bosun’s fatal fall through an open hatch aboard Seatruck Pace in Liverpool. It analyses temporary edge barriers, trailer trestle use during hatch-cover maintenance, risk assessments and permit arrangements. The report identifies weaknesses in safety culture and records management actions; no recommendations were made.
- 201925 Jun
DuPont La Porte Facility Toxic Chemical Release
Investigation of a fatal methyl mercaptan release at DuPont’s La Porte insecticide unit. Four workers died inside the manufacturing building. The report examines hydrate-blocked pipework, drain valves, inadequate safeguards, alarm communication and emergency response, alongside management of change, audit effectiveness, process safety culture and misleading reliance on occupational injury metrics.
- 20195 Apr
Personal injury following PPE violation and slip and fall on deck
A vessel Master slipped on a wet main deck during routine checks without safety footwear or a helmet, suffering head abrasions. The flash emphasises PPE compliance, leadership example and expectations to challenge unsafe behaviour through stop-work intervention. A formal warning followed the deliberate procedural violation.
- 201813 Dec
Crush incident involving a falling hatch cover on general cargo vessel SMN Explorer with loss of 1 life
This investigation examines a fatal hatch-cover crushing on SMN Explorer at Alexandra Dock, King’s Lynn. The crewman climbed the open cover after its locking pins were removed, before crane support was established. Analysis addresses inadequate procedures, supervision, lifting-equipment maintenance and safety culture, with recommendations to redesign access arrangements and improve fleet management.
- 201817 Oct
Heavy contact made by container vessel CMA CGM Centaurus with quay and shore cranes
Investigation of CMA CGM Centaurus striking a pontoon and shore cranes at Jebel Ali, causing crane collapse and ten injuries. Simulator trials examined turning performance. Findings address excessive approach speed, unavailable tug assistance, deficient master–pilot information exchange, absent shared planning and pressure to complete pilotage quickly.
- 2018Aug
Life-Saving Rules (IOGP Report 459)
Introduces nine revised Life-Saving Rules for oil and gas workers, supported by analysis of reported fatalities from 2008–2017. Explains organisational conditions for implementation, leadership commitment, ongoing engagement and integration with existing management systems. Provides guidance on hazardous activities, work authorisation, energy isolation and personal safeguards.
- 201820 Jun
Grounding of general cargo vessel Ruyter
Investigation of Ruyter’s grounding at Rathlin Island examines an unattended bridge, disabled watch alarms and absent night lookout. It analyses alcohol consumption, inadequate company oversight and normalised departures from watchkeeping instructions. Hull damage caused flooding; the vessel refloated without assistance. Subsequent company action included random alcohol testing and crew reporting empowerment.
- 201823 Jan
High potential near miss: AB slipped over the side during mooring operations
An able seaman slipped into the sea while jumping from a vessel to the quay during mooring. He held a fender, and the Master manoeuvred to prevent crushing and propeller exposure. The flash examines procedural violations, failure to intervene and management acceptance of an unsafe practice.
- 20177 Nov
Two yard-based fatal road traffic accidents (UK HSE)
This safety flash describes two fatal yard vehicle incidents: uncontrolled forward movement during HGV coupling and a pedestrian struck by a reversing telehandler. HSE findings address coupling systems, trailer parking brakes, driver training and pedestrian segregation. IMCA highlights traffic management and safety culture within subcontracted haulage.
- 201718 Sep
ExxonMobil Baton Rouge Refinery Chemical Release and Fire
This safety bulletin examines an isobutane release and fire at ExxonMobil’s Baton Rouge refinery that seriously injured four workers. It analyses plug valve gearbox removal, pressure-retaining bolt arrangements, design ambiguity and organisational practices. Lessons address safer valve designs, human-factors hazard analysis, written removal procedures and operator training.
- 201725 Jul
High potential incident: Fast rescue craft capsized
A fast rescue craft capsized during a near-shore seismic survey after towed equipment snagged on the seabed and weather deteriorated. Four people entered the sea without injury. The flash discusses overridden stop-work intervention, loading limits and emergency arrangements, alongside two further small-boat incidents involving swell, collision and floating hoses.
- 201713 Jul
Fall from height during yard visit
A yard worker fell 4 m while helping manually lower grating through a deck opening, fracturing his right ankle. His fall arrester was not anchored. The flash examines team organisation, language barriers, unused taglines and absent task-specific analysis, emphasising closer yard oversight and executive commitment to safety culture.
- 201712 Apr
Accidents on board yacht CV21 resulting in loss of 2 lives
Investigates two fatal accidents aboard racing yacht CV21: a neck injury during uncontrolled gybes following preventer strop failure, and a crew member washed overboard. Analysis examines HMPE rope loading, tethering practices, supervision, survival equipment and recovery delays, with recommendations addressing procedures, training and personal AIS beacons.
- 201622 Dec
Collision between general cargo vessel Daroja and oil bunker barge Erin Wood
Investigation of the collision between Daroja and Erin Wood south-east of Peterhead on 29 August 2015. It examines absent lookouts, lone watchkeeping, unused navigational aids, crew competence and safety-management shortcomings. Collision damage and open weathertight doors caused flooding; the report also analyses emergency pumping, fuel leakage and regulatory oversight.
- 20169 Nov
Fatal fall from tug Svitzer Moira
This safety flash summarises MAIB findings on a fatal fall and crushing during tug manoeuvring at Royal Portbury Dock. It highlights the absence of a toolbox talk, inadequate oversight of deck operations and divergence from company instructions. Appropriate PPE was not worn, although its use was unlikely to have altered the outcome.
- 20167 Oct
Fall from tug Svitzer Moira with loss of 1 life
Investigates an engineer’s fatal crushing between two tugs at Royal Portbury Dock. He probably fell while transferring before the vessels were fully alongside, possibly through slipping or tripping. The report examines deck supervision, communications, mooring procedures, PPE use and comparative footwear slip-resistance testing, alongside company and port actions.
- 20166 Oct
Man overboard from twin rig trawler Aquarius with loss of 1 life
Investigates a fatal overboard accident east of Aberdeen during trawl-warp marking aboard Aquarius. A fibre-rope stopper failed, causing the warp to tighten and throw a crewman into the sea. Analysis examines stoppering practice, absent flotation protection, inadequate recovery preparation, fragmented rest, risk assessment shortcomings and poor onboard safety culture.
- 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.
- 201613 Sep
Dropped pallet during loading of stores
A pallet struck a deck hatch during stores loading from quayside to vessel, releasing most of its contents onto the deck below. The flash examines omitted securing chains, unclear lifting responsibilities and reluctance to challenge a supervisor. Actions address toolbox talks, lift planning, load securement and staged lowering through blind openings.
- 20161 Sep
Fire in the engine room on the suction dredger Arco Avon with loss of 1 life
Investigation of a fatal engine-room fire aboard Arco Avon during an attempted fuel-pipe repair. It identifies portable angle-grinder sparks as the probable ignition source and examines pipe fretting, hot-work controls, lone working, protective clothing, CO2 system operation and medical response. Recommendations address maintenance inspections and safety-management implementation.
- 20162 Aug
Tesoro Martinez Sulfuric Acid Spill
CSB case study examines two sulfuric acid releases at the Martinez refinery in February and March 2014, injuring four workers. It analyses sampling-system integrity, protective equipment, pipe preparation and isolation, alongside process safety culture and missed incident learning. Comparisons with other refineries inform discussion of safer sampling arrangements.
- 201620 Apr
Capsize and sinking of cement carrier Cemfjord with loss of 8 lives
Investigation of Cemfjord’s rapid capsize in the Pentland Firth and subsequent sinking, with eight crew assumed lost. AIS, radar, environmental modelling and underwater surveys inform analysis of violent seas, passage planning, cargo stability and probable fatigue. The report also examines rescue-boat incompatibility, bilge pumping deficiencies and ineffective regulatory assurance.