Safety Flash: Crewman fell to his death through faulty grating

3 min read

The United States’ Bureau of Safety and Environmental Enforcement (BSEE) has published BSEE Panel Report 2021-001 into a fatal fall from a platform in the Gulf of Mexico in 2019.

Pre-Incident photograph of the hazardous grating section

Post-Incident photograph of hazardous grating section suspended in open hole

Post-Incident Photograph of person standing near the open hole

What happened

A night shift production operator died when he fell into the sea through a rusty grating on the platform. His body was never recovered. Less than 24 hours prior to the incident, a single section of severely corroded and deteriorated grating, posing a walking and working surface hazard, was identified on the north side of the well bay by a supervisor, who said that the grating section felt “spongey” underfoot. Upon examination, he found that bearing bars at one end of the grating section had deteriorated.

What were the causes?

The investigation by BSEE found several probable and possible causes – including communication breakdown, poorly maintained walking surfaces, and inadequate barricade installation.

There was a failure to maintain all walking and working surfaces on the facility in a safe condition;
Supervisors did not fulfill their responsibilities within the relevant, established Safe Work Practices (SWPs) when they:
- failed to promptly correct or prevent personnel from accessing the hazardous area;
- failed to stop work and warn all personnel of the hazardous area.
The operator and its contractors failed to follow the agreed-upon terms and conditions within their respective Safety and Environmental Management Systems (SEMS) bridging arrangements.

Recommendations included:

Ensure crew are informed about all identified hazards in a timely and meaningful way;
When hazards are identified, fix them;
A better understanding of and agreement between, operators and contractors in terms of safety management systems bridging arrangements.

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These flashes summarise key safety matters and incidents, allowing wider dissemination of lessons learned from them. The information below has been provided in good faith by members and should be reviewed individually by recipients, who will determine its relevance to their own operations. The effectiveness of the safety flash system depends on receiving reports from members in order to pass on the information and avoid repeat incidents.