Topic
Learning from Incidents
Systems or methods for sharing and applying incident learning.
Newest 100 Documents
All 144 in search- 202612 Feb
Safety warning (video) issued following the capsize and sinking of the tug Biter while assisting the passenger vessel Hebridean Princess with the loss of two lives
This MAIB bulletin announces a video sharing lessons from the fatal capsize and sinking of Biter while assisting Hebridean Princess. It places the investigation within a series of conventional tug capsizes and recommends that named shipping, harbour, pilotage, tug and workboat associations distribute the video to their members.
- 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.
- 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.
- 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.
- 202523 Jan
Safety Flashes – a review of 2024
Reviews IMCA’s 2024 Safety Flashes, covering 88 member-shared events and 33 drawn from public sources. Highlights line-of-fire exposure, hand and finger injuries, bypassed safety controls, lifting, working at height, equipment failures and dropped objects. Includes a reference list of the year’s flashes and reinforces stop-work authority.
- 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 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.
- 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
MAIB Safety Digest 1/2024
This marine accident digest presents lessons from merchant shipping, commercial fishing and recreational craft incidents. Cases examine pilot ladders, navigation, mooring machinery, suspended loads, falls and recovery from the water. Reproduced bulletins and flyers address RIB passenger injuries, dredging-chain failures, fire-extinguishing systems and flotation-device suitability.
- 2024
MAIB Safety Digest 2/2024
A collection of marine accident accounts and preventive lessons spanning merchant shipping, commercial fishing and recreational boating. Cases examine steering and propulsion failures, mooring injuries, grounding, fire, flooding and capsize. Lessons address maintenance, navigation, risk assessment, equipment interfaces, watertight integrity and emergency evacuation, alongside reproduced safety bulletins and flyers.
- 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.
- 202316 Mar
Broken Breaker Bar Injury with Medical Evaluation Guidance
A wrongly sized breaker bar fractured during star-nut removal, causing a worker to fall into a steel beam and sustain dental and lip injuries. The alert shares tool inspection, selection, positioning and stop-work lessons, and recommends considering medical-treatment options, worker privacy and regulatory reporting obligations.
- 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
MAIB Safety Digest 2/2023
A multi-case marine safety digest draws lessons from navigation incidents, fires, falls, cargo lifting, mooring injuries and fishing casualties. Case analyses examine communication, electrical work, lifejacket use and recovery arrangements. Reproduced bulletins and flyers address fuel-hose modifications, liferaft servicing, carbon monoxide poisoning and fatal man-overboard incidents.
- 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.
- 202226 Jul
MSF: CO2 system left non-operational after servicing
A vessel’s fixed CO2 firefighting system remained inoperable because survey safety pins were not removed, discovered almost four weeks later. The flash reinforces owner-specific lessons on isolation records, considering permits to work, inspecting contractor reinstatement and circulating safety learning, while noting that incident-specific causes and corrective actions were not supplied.
- 202222 Jul
Damage to flexible riser
A water injection riser suffered outer-coating damage against a sharp moonpool flare during installation through a vessel’s tilted lay system. The flash identifies missed design hazards, inadequate risk controls and failure to transfer earlier lessons. Recommendations address lifecycle learning, sharp-edge mitigation and vessel-team review of project-supplied equipment.
- 20228 Apr
MAIB Safety Digest 1/2022
This safety flash announces the MAIB’s first safety digest of 2022, sharing lessons from marine accident investigations to help prevent recurrence. It lists cases involving flooding, grounding, collisions, accommodation fire, machinery failure, finger injury, pilot ladder failures and a person overboard.
- 2022
MAIB Safety Digest 2/2022
A collection of marine accident lessons covering merchant ships, fishing vessels and recreational craft. Cases examine groundings, fires, towing and lifting failures, flooding, capsize and people overboard. Reproduced bulletins and flyers discuss blocked CO2 pilot hoses, vessel stability, flotation and distress alerting, alongside navigation, training and equipment checks.
- 202121 Sep
NTSB – Safer Seas Digest 2020
This safety flash introduces the NTSB’s Safer Seas Digest 2020, drawing lessons from 42 maritime accidents. It outlines casualty types and categorised safety issues, including fatigue, voyage planning, fire precautions and inspection. The digest also covers the sinking of the liftboat Kristin Faye.
- 202111 Aug
Step Change in Safety – Major Accident Hazard (MAH) Awareness
This safety flash introduces a Step Change in Safety mini-alert pack for proactive conversations about barriers to major accidents. Drawing lessons from oil and gas and other industries, the pack outlines accident circumstances and failures, with discussion points linked to the 7 Cs of Safety.
- 202120 Jul
Cargo tank explosion and fire on chemical tanker Stolt Groenland
Investigation of the Stolt Groenland explosion and fire at Ulsan examines runaway styrene polymerisation following heat transfer through an intermediate cargo tank. It analyses inhibitor depletion, stowage planning, unused temperature monitoring and alarms, and onboard remedial limitations. Fire response and missed learning from the separate Stolt Focus incident are also considered.
- 20212 Jun
UK HSE: Employee in a port suffers life changing injuries in clamp truck incident
A port employee suffered injuries requiring leg amputation after being struck by a five-tonne clamp truck in a paper reel shed. The flash describes unsafe pedestrian–vehicle interaction, inadequately reviewed supervisory activities and missed learning from earlier incidents. HSE recommends separating pedestrians through physical barriers or clear, well-supervised safe systems of work.
- 20216 May
CHIRP Maritime – Annual digest for 2020
This safety flash introduces CHIRP Maritime’s 2020 annual digest and explains its independent, confidential reporting approach and dissemination of disidentified safety information. It outlines the digest’s subject areas and highlights an article examining the psychological effects on seafarers unable to return home during the COVID-19 pandemic.
- 20216 May
UK MAIB: Safety Digest – Lessons from marine accident reports 1/2021
This IMCA safety flash introduces MAIB Safety Digest 1/2021, which shares lessons from recent marine accident investigations to help prevent recurrence. It highlights the merchant-vessel section as particularly relevant to members, while noting potential learning from sections covering fishing vessels and recreational craft.
- 202121 Jan
Risk-Based Inspections of Subsea Leak Detection Technology Reveals Gaps in System Processes
BSEE reviews three subsea oil leaks and inspection findings showing weaknesses in leak-detection procedures and management processes. Operators and contractors are asked to consider clearer alarm response responsibilities, personnel training, system testing, configuration change control and ROV surveys. The alert emphasises investigating abnormal flow and learning from previous detection failures.
- 202119 Jan
Positive: Vessel improvements made following a man overboard incident
Following a non-fatal fall overboard from a tug, a member reviewed bow transfers and introduced removable handrails and refresher training. Subsequent dry-dock modifications created a larger, obstruction-free embarkation platform with improved fendering and hazard markings. Similar tugs were scheduled for modification as they docked over the following 12–18 months.
- 2021
CHIRP Annual Digest 2021
This annual maritime digest combines confidential incident reports with specialist insights into human performance and seafarer wellbeing. Cases examine pilot boarding, mooring, propulsion failures, fires and maintenance. Commentary discusses fatigue management, risk assessment and communication, alongside trauma-informed interviewing and confidential reporting arrangements.
- 2021
MAIB Safety Digest 2/2021
A collection of merchant, fishing and recreational vessel cases examines navigation errors, mooring hazards, machinery fires, flooding and immersion. Lessons address task planning, supervision, maintenance, enclosed-space precautions and emergency readiness. Appendices list investigations and reports and reproduce provisional guidance on anchor failures during prolonged cruise-ship anchoring.
- 202026 Nov
Crush incident on general cargo vessel Karina C with loss of 1 life
The supplied investigation annexes document Karina C’s hatch-cover gantry-crane risk assessments before and after an accident, alongside operating procedures and safety-management records. They address crushing exposure, crane movement, crew communication and training, and include dusty-cargo precautions, alcohol restrictions, incident reporting and fleet sharing of corrective actions.
- 2020Oct
MAIB Safety Digest 2/2020
A collection of marine accident lessons covering merchant vessels, commercial fishing and recreational craft. Cases examine collisions, grounding, machinery failures, overboard accidents, scalding and fire. Discussions address navigation information, lifejackets, maintenance checks and recovery arrangements. An appended provisional bulletin considers precautions for condensed aerosol fire-extinguishing systems.
- 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.
- 2020Apr
MAIB Safety Digest 1/2020
A collection of lessons from accidents involving merchant vessels, fishing boats and recreational craft. Cases examine distracted navigation, grounding, machinery fires, hazardous tank atmospheres, cargo handling and overboard emergencies. Discussions cover passage planning, maintenance, atmospheric testing, lifejacket performance and emergency drills, retaining uncertainty where accident causes remain unresolved.
- 202026 Feb
High potential near miss: Dropped object from turbine tower
A safety flash describes 17 kg of chain falling 84 m inside a wind turbine tower during high-voltage cable installation, without injury. The investigation identified unimplemented learning from an earlier incident and a distracted spotter. Actions address crew competence, dissemination of incident learning and stopping work when spotting cannot continue.
- 2019Oct
MAIB Safety Digest 2/2019
A collection of marine accident lessons spanning merchant shipping, commercial fishing and recreational boating. Cases examine collisions, grounding, machinery failures, falls, fires and people overboard. Discussions emphasise passage planning, bridge teamwork, equipment maintenance, lifejackets, realistic recovery arrangements and emergency drills, with reproduced bulletins on vehicle-deck safety and retractable ballast securing.
- 201918 Apr
Unpublished safety incidents
IMCA explains its editorial reasons for leaving submitted incidents unpublished, including limited learning value, inadequate reporting and missing publication permission. It discusses clarity, proportional detail, corrective actions and supporting images, emphasising coherent incident stories that support safety improvements. A topical list summarises 33 unpublished incidents without detailed case analysis.
- 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.
- 2018Oct
MAIB Safety Digest 2/2018
A collection of marine accident lessons covering merchant vessels, fishing boats and recreational craft. Cases examine navigation errors, flooding, machinery failures, fires, scalding, overboard emergencies and carbon monoxide poisoning. Discussion addresses electronic chart checks, alarm use, maintenance, risk assessment and practised emergency procedures, with appended rescue-line and yacht-keel safety bulletins.
- 201827 Jun
Grounding and loss of commercially operated yacht CV24
Investigation of CV24’s grounding and loss off Cape Peninsula during the Clipper round the world race. It examines positional awareness, competing navigation and deck-supervision demands, electronic chart access, passage planning, manning and safety management. The crew were rescued uninjured; recommendations address navigation procedures, training and organisational assurance.
- 201824 Apr
Packaging Corporation of America Hot Work Explosion
Investigation of a foul condensate tank explosion at PCA’s DeRidder mill that killed three contractors and injured seven. Air ingress created an explosive atmosphere; nearby hot work was the probable ignition source. The report examines turpentine recovery, outage conditions, permit limitations, process safety boundaries and explosion safeguards, with comparisons to earlier incidents.
- 2018Apr
MAIB Safety Digest 1/2018
A collection of marine accident lessons covering merchant, fishing and recreational vessels. Cases examine collisions, groundings, flooding, fires and personnel injuries, with attention to navigation, towing, maintenance and emergency readiness. Equipment-specific discussions include pilot-ladder deterioration, bilge-pump blockage, carbon monoxide alarms and safety-tether hook deformation under lateral loading.
- 201725 Oct
Two near miss incidents with a risk of scalding
Two vessel near misses involved scalding water: boiler blowing sent water from the funnel onto the boat deck, while engine shield installation dislodged a cooling water pipe. Lessons address failure to embed previously recognised hazards into routines, reassessment as work becomes more complex, system isolation and communication of maintenance tasks.
- 2017Oct
MAIB Safety Digest 2/2017
Marine accident cases draw lessons for merchant vessels, fishing boats and recreational craft. They examine fires, collisions, lifting failures, falls, entanglement, flooding and emergency recovery. Practical discussions cover navigation aids, risk assessment, drills and equipment integrity. An appended safety bulletin examines low-sulphur marine gas oil waxing and cold-temperature fuel testing.
- 201722 May
High potential near-miss: Incorrectly secured overhead equipment
Loose shackle pins on two overhead fall arrest inertia reels presented a potentially fatal dropped-object risk. Incorrect securing clips had fallen out, while weather protection boxes hindered inspection. The flash highlights unshared previous findings and recommends appropriate pin retention, checks of overhead equipment, suitable inspection arrangements and assurance of third-party installation work.
- 201720 Apr
AirGas Facility Fatal Explosion
CSB investigates the fatal nitrous oxide explosion at Airgas in Cantonment, Florida, on 28 August 2016. Probable initiation involved transfer-pump heating during trailer loading, although the initiating event remains uncertain. Analysis examines flame arrestors, interlock design, pump changes and process safety management, alongside earlier explosions and recommendations for inherently safer design.
- 2017Apr
MAIB Safety Digest 1/2017
A multi-case digest draws preventive lessons from merchant shipping, fishing and recreational boating accidents. It examines navigation, vessel flooding, fires, machinery injuries and people entering the water, with particular attention to unnecessary risk-taking, equipment suitability, maintenance, risk assessment and effective casualty recovery.
- 201624 Oct
Dropped object awareness
This safety flash highlights increased reporting of dropped and potential dropped objects by one vessel owner despite reduced exposure. It draws attention to back-loaded cargo, suggests renewed scrutiny of loading operations, and recommends staying clear of lifts until safe to approach, prompt reporting and stakeholder sharing of lessons.
- 2016Oct
MAIB Safety Digest 2/2016
This digest draws preventive lessons from merchant, fishing and recreational vessel accidents. Cases examine groundings, collisions, capsizing, flooding, machinery injuries and fires. Analysis addresses passage planning, bridge communication, maintenance, risk assessment and emergency checklists, alongside flotation equipment and distress beacons. A reproduced bulletin discusses carbon monoxide poisoning aboard a motor cruiser.
- 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.
- 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.
- 201630 Jun
Near-miss: Bilge cover left open
Crew found an unguarded open bilge cover in a vessel’s engine room after brine pump maintenance was interrupted. Similar earlier near misses had already been discussed across the fleet. The flash describes closing the covers and a safety stand down, and stresses risk assessment, control of openings and effective supervision.
- 201627 Jun
Vessel loss of position while diving in close proximity to a hydrocarbon facility
A diving vessel drifted over 40 metres after inadvertent deselection of its surge control disabled automatic positioning. A diver noticed his umbilical becoming taut. The alert examines vulnerable console layout, absent confirmation and ineffective excursion feedback, highlighting interface design and safeguards against unintended deactivation.
- 2016
Beyond Compliance: Strengthening the Safety Culture of the Offshore Oil and Gas Industry
This companion summary examines how the offshore oil and gas industry can strengthen safety culture beyond compliance. It addresses leadership commitment, regulatory frameworks, workforce participation and organisational learning. Culture assessment combines surveys, focus groups and leading and lagging indicators, with emphasis on trust, contextual interpretation and continuing improvement.
- 201519 Nov
Small change to the disclaimer for all safety flashes
IMCA clarifies its safety-flash disclaimer following reports that clients required members to change operations or undertake additional activity based on flash content. Recommendations originate from submitting organisations rather than IMCA, and the information does not replace individuals’ or members’ legal and operational responsibilities.
- 20152 Oct
High potential incidents and fatalities in 2014 – International Association of Oil & Gas Producers (IOGP)
This safety flash announces two IOGP reports covering high-potential and fatal incidents in 2014. It directs readers to the IOGP publications library and notes their potential learning value for IMCA members, without presenting individual cases, equipment details or specific preventive measures.
- 2015Oct
MAIB Safety Digest 2/2015
A compilation of 25 marine accident articles shares lessons for merchant vessels, fishing boats and small craft. Cases examine collisions, grounding, mooring casualties, fire, flooding and people entering the water. Lessons address supervision, briefings, navigation equipment, lifejacket reliability and emergency preparations, with additional analysis of synthetic mooring-line recoil.
- 2014Oct
MAIB Safety Digest 2/2014
A collection of marine accident accounts and preventive lessons covering merchant vessels, fishing boats and small craft. Cases examine groundings, collisions, fires, flooding, mooring injuries and rescue difficulties. Discussions address navigation equipment, watchkeeping fatigue, crew coordination, emergency drills and equipment readiness, with an appended bulletin on oxygen depletion and unsafe rescue attempts.
- 201413 May
Crew transfer vessel in collision with anchor wire
An offshore wind crew transfer vessel suffered partial propulsion loss following an engine alarm and automatic engine-management intervention while approaching a cable lay barge. Current carried it into a tensioned anchor wire, damaging the wheelhouse without injuries. The flash stresses project-specific transfer risk assessment and reporting, communication and follow-up of earlier incidents.
- 2014Feb
Are we reliving past incidents? — Process Safety Beacon, February 2014
This bulletin compares recurring storage-tank fires involving carbon adsorbers in Norway and Georgia, USA. Adsorption heat and the absence of flame arresters were shared design problems. It advocates retaining and sharing incident knowledge, reviewing events elsewhere, and evaluating new hazards introduced by environmental protection equipment through process hazard analysis and management of change.
- 2014
Safe Science: Promoting a Culture of Safety in Academic Chemical Research
This research report examines safety culture in academic chemistry laboratories through incident cases, organisational analysis and experience from other sectors. It addresses leadership, power differences, researcher participation and practical training, recommending integrated hazard analysis, non-punitive reporting and leading indicators rather than reliance on regulatory compliance alone.
- 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.
- 201329 Nov
Serious DP diving incident
A diving support vessel lost DP control following RBUS communication failure and drifted 240 m. A diver’s snagged umbilical severed, interrupting gas, hot water and communications. The flash describes recovery and medical monitoring, investigation findings without a definitive jamming cause, a firmware remedy and an improvement project for diving and marine operations.
- 2013Nov
Contact made by wind farm passenger transfer catamarans: Windcat 9 with floating target and Island Panther with turbine
Investigates two wind-farm transfer catamaran accidents on 21 November 2012. Windcat 9 struck a floating target and suffered extensive flooding; Island Panther struck an unlit turbine transition piece. The report examines passage monitoring, chart-plotter use, crew competence, navigation warnings and emergency arrangements, with recommendations for training and sharing industry lessons.
- 201317 Oct
What is a Safety Flash?
Explains how IMCA safety flashes share incident learning and help prevent recurrence. Describes confidential submission, anonymisation, technical review and originator approval before publication. Provides writing pointers covering concise titles, incident circumstances, causes, learning and recommendations, with sufficient detail to communicate risks and precautions without identifying those involved.
- 2013Oct
MAIB Safety Digest 2/2013
A collection of marine accident lessons covering merchant vessels, fishing vessels and small craft. Cases examine collisions, machinery failures, overboard emergencies, stability and fire. Discussion emphasises communication, maintenance, passage planning and realistic emergency drills. Reproduced safety bulletins address kill cords and fatal carbon monoxide poisoning aboard a motor cruiser.
- 2012Oct
MAIB Safety Digest 2/2012
A collection of marine accident narratives and lessons for merchant vessels, fishing boats and small craft. Cases examine collisions, groundings, mooring fatalities, fires, equipment failures and people overboard. Discussion covers ECDIS alarms, rope condition, rescue-craft recovery, passage planning, risk assessment and emergency drills. Appendix coverage dates concern investigations started, not the case incidents.
- 2011Nov
Contact made by container vessel CMA CGM Platon with wharf
Investigation of CMA CGM Platon’s contact with Bevans Wharf during departure from Tilbury. It examines complex tidal flows, delayed helm application, early tug release and limited master–pilot discussion. Simulator exercises informed the analysis, with recommendations addressing tug retention and findings on dissemination of pilotage lessons.
- 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.
- 201119 Oct
Texas Tech University Chemistry Lab Explosion
This case study examines an energetic-material laboratory explosion at Texas Tech University. It analyses synthesis scale-up, mortar-and-pestle handling, eye protection, research-specific training and supervisory oversight. Findings address physical-hazard assessment, written protocols, organisational accountability and missed opportunities to learn from earlier incidents, with recommendations for universities and research funders.
- 2011Oct
MAIB Safety Digest 2/2011
This marine accident digest presents separate cases involving navigation, propulsion failures, cargo handling, flooding, fishing hazards and passenger safety. Lessons examine bridge teamwork, training, emergency drills and equipment checks. Reproduced Tombarra bulletins analyse rescue-boat weight, water retention and davit overload protection; hull cases discuss ultrasonic thickness measurement and visual inspection.
- 201119 Apr
Crane boom dropped object
Wood detached from a crane boom rest on an offshore construction vessel, stuck to the boom and fell an estimated 20 metres onto the deck without injury. The flash identifies deficient fixings, inspections and reporting, and describes securing and replacing wood, improving inspection access and planned maintenance, and circulating incident information.
- 2010Jul
Collision between offshore circuit racing powerboats Sleepwalker and Harwich 2011 with loss of 1 life
MAIB examines a fatal collision between Sleepwalker and Harwich 2011 during powerboat racing in Dover harbour. Video analysis and specialist racing advice supported the investigation. The report discusses hooking, course design, conflicting rules, risk assessment, racer competence, helmet limitations and safety-management oversight, while recognising the effective on-water emergency response.
- 2010Feb
Lest We Forget! — Process Safety Beacon, February 2010
This centenary issue urges process-industry personnel to preserve and apply lessons from past events. It recommends asking experienced workers about incidents, documenting event histories, sharing lessons with newcomers and using incident logs in hazard reviews. A second page recognises volunteer translators and the Beacon’s multilingual reach.
- 2010
MAIB Safety Digest 2/2010
Marine accident digest presenting separate cases involving merchant vessels, fishing boats and small craft. Lessons examine navigation, towage, mooring winch settings, lifting, maintenance permits, flooding and person-overboard recovery. Case analyses distinguish equipment defects from communication and supervision shortcomings. Appendices list examinations and investigations started between March and September 2010.
- 2009Dec
MAIB Safety Digest 3/2009
This marine accident digest presents cases involving merchant vessels, fishing boats and small craft, with lessons on navigation, flooding, fire, stability and recovery from water. It examines unused watchkeeping aids, hot-work precautions, crane corrosion, hazardous winch arrangements and lifejacket suitability, alongside risk assessment and emergency preparation.
- 2009Dec
The Bhopal Tragedy – 25 Years Ago — Process Safety Beacon, December 2009
This anniversary bulletin revisits the Bhopal methyl isocyanate release, with an accompanying 2004 Beacon. It describes water contamination, an exothermic reaction and inadequate safety systems, while retaining uncertainty over the water source. Lessons address reactive hazards, safe relief discharge, maintenance, change evaluation and emergency procedures.
- 2009Aug
MAIB Safety Digest 2/2009
A collection of preventive lessons from merchant-vessel, fishing and small-craft accidents. Cases examine collisions, fires, flooding, capsizing and people overboard, alongside navigation, towing and maintenance. Lessons address vessel-specific risk assessment, bridge teamwork, electrical isolation, watertight-door operation, lifejacket use and correct preparation of survival equipment.
- 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.
- 2009May
MAIB Safety Digest 2009 — Fishing edition
A collection of fishing-vessel accident accounts and lessons covering overboard losses, collisions, groundings, flooding, fires and machinery injuries. Case discussions examine lookout practices, radar settings, lifejackets, watertight arrangements, machinery guarding and emergency pump testing. Rescue guidance and watchkeeping recommendations address casualty recovery and crew work–rest patterns.
- 2008Feb
How Can You Use “The Beacon”? — Process Safety Beacon, February 2008
This bulletin explains how incident learning can sustain awareness of process hazards when good performance risks complacency. It suggests progressively richer uses of the Beacon: displaying it, discussing it with workers, connecting lessons to local operations and near misses, and involving plant management and safety committees in identifying further lessons.
- 2008Jan
2007 Beacon Review – Remember the Lessons Learned! — Process Safety Beacon, January 2008
This annual Beacon review recalls selected 2007 subjects, including tank collapse, temporary confined spaces, safety culture, emergency response, cold embrittlement and hot-work permits. It acknowledges volunteer translators and explains access to the searchable archive, distinguishing free viewing from printable access through SACHE membership.
- 2008
MAIB Safety Digest 2/2008
A collection of accident accounts and lessons spanning merchant shipping, commercial fishing and leisure craft. Cases examine engine-room fires, enclosed-space dangers, rescue-boat machinery failures, cargo sampling and securing, navigation, flooding and capsizing. Lessons address practical risk assessment, maintenance, safety-critical testing, training and coordination between crews and contractors.
- 2008
MAIB Safety Digest 2008 — Leisure craft edition
A compilation of 23 leisure-craft accident cases explores capsizing, people overboard, propeller injuries, steering failure and onboard hazards. Lessons address lifejacket fit, crew recovery skills, navigation aids, novice-crew risk assessment and machinery guarding. Yacht, motorboat and narrowboat narratives distinguish reported outcomes from uncertain accident sequences.
- 2007Mar
Formosa Plastics Vinyl Chloride Explosion — Final Investigation Report
Investigation of the fatal vinyl chloride release, explosion and fire at an Illinois PVC plant. It examines reactor valve interlock bypassing, operator access to status information, safeguard assessment and missed learning from earlier incidents. Emergency procedures, training and deluge limitations underpin recommendations for stronger process safeguards and preparedness.
- 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.
- 2006Jul
MAIB Safety Digest 2/2006
This marine accident digest presents cases involving merchant ships, fishing vessels and leisure craft. Lessons examine lookout, passage planning, fatigue, firefighting, lifting injuries, lifeboat failures, flooding and capsize. Case analyses emphasise suitable training, clear briefings, risk assessment and emergency arrangements. Appendices list examinations, investigations and issued reports.
- 2005Dec
MAIB Safety Digest 3/2005
This marine accident digest draws lessons from merchant, fishing and leisure vessel cases involving grounding, fire, flooding, instability and lifting failures. It examines passage planning, equipment maintenance, cargo handling and emergency actions, including CO2 suppression limitations, watertight closures, lifeboat brake failure and navigation aids. Accounts remain provisional pending further evidence.
- 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.
- 2005Jul
Grounding of passenger vessel Balmoral
Investigation of Balmoral’s grounding on Dagger Reef during a coastal sightseeing excursion. Both propellers were damaged, while the hull remained watertight. The report examines route deviation, inadequate position monitoring, navigation equipment and weaknesses in safety-management assurance, with recommendations addressing navigational risk assessment, procedure compliance and accurate passenger information during emergencies.
- 2005May
MAIB Safety Digest 2005 — Fishing edition
This fishing safety digest presents accident narratives and preventive lessons on vessel alterations, stability, flooding, fires, collisions and crew injuries. Cases examine bilge alarms, pumping, watertight subdivision, winch controls and watchkeeping. Lessons also address emergency preparedness, accessible lifesaving equipment, electrical installation and risk assessment around open hatches.
- 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.
- 2004Nov
MAIB Safety Digest 3/2004
This marine accident digest presents lessons from merchant, fishing and leisure vessels, covering navigation failures, groundings, collisions, flooding, fires and people lost overboard. Case discussions examine chart plotters, rescue craft, lifejackets and maintenance, with recommendations on risk assessment, bridge teamwork, watertight subdivision, hatch guarding and liferaft release arrangements.
- 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.
- 2004
MAIB Safety Digest 1/2004
This digest presents lessons from 27 marine accidents and incidents involving merchant ships, fishing vessels and leisure craft. Cases examine navigation, mooring, lifeboat launching, fires, flooding and stability. The discussion highlights risk assessment, equipment maintenance, operating procedures and emergency arrangements, including winch brake adjustment and carbon-dioxide fire suppression.
- 2004
MAIB Safety Digest 2/2004
This marine accident digest presents lessons for merchant vessels, fishing vessels and leisure craft. Cases examine watchkeeping, collision avoidance, grounding, lifeboat launching, fires, flooding and evacuation drills. It discusses passage appraisal, equipment inspection, risk assessment, water-fog suppression, watertight integrity and the accessibility of emergency equipment.
- 2004
MAIB Safety Digest 2004 — Leisure craft edition
This collection brings together 25 leisure-craft accident articles and their lessons. Sailing yachts, dinghies and powerboats feature in capsizes, groundings, flooding and overboard emergencies. Discussion examines navigation, heavy-weather tactics, lifejacket and harness use, watertight closures, rescue-boat suitability, survivor accounting, safety briefings and skipper rest.
- 2003Aug
MAIB Safety Digest 2/2003
This marine accident digest presents lessons from merchant shipping, fishing and leisure craft cases. It examines collisions, groundings, cargo securing, chemical exposure, machinery injuries and people overboard. Case discussions emphasise vigilant lookouts, bridge-team communication, radar monitoring, equipment checks, consistent instructions and preparation for recovering people from the water.
- 20033 Jul
Fatality: Pressure build-up leading to sudden release of mechanical plug
A welder died when pressure behind a non-pressure-containing mechanical plug ejected it during welding on produced-water pipework. Freezing water vapour blocked the nitrogen purge vent. The flash examines inadequate vent monitoring, hazard analysis and incorporation of earlier near-miss lessons, and describes revised isolation, purging and pressure-control procedures.
- 2003Mar
MAIB Safety Digest 2003 — Fishing edition
This fishing safety digest draws lessons from collisions, near misses, groundings, flooding, capsizes and deck accidents. Cases examine lookout practices, fatigue, navigation equipment, bilge alarms and pumping reliability. Practical lessons address machinery guarding, lifejacket use, valve checks and emergency measures to reduce water ingress.