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BSEE: Crewman fell to his death through faulty grating

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.

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.

Pre-Incident photograph of hazardous grating section
Post-Incident photograph of hazardous grating section suspended in open hole
Post-Incident Photograph of person standing near the open hole
Post-Incident Photograph of hazardous grating section

What were the causes?

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;  
  • Better understanding of and agreement between, operators and contractors in terms of safety management systems bridging arrangements.

The full report can be downloaded here:

Safety Event

Published: 16 April 2021
Download: IMCA SF 11/21

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