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Notice of order after investigation into personal injury on Goliat

The PSA has completed its investigation of an incident involving a serious personal injury on the Goliat field on 25 June 2016. Serious breaches of the regulations have been identified, and the PSA has given operator Eni notice of an order.


A deck operator on the Goliat facility in the Barents Sea was seriously injured at about 10.55 on 25 June 2016. He was hit on the head by wire rope being reeled in using a work winch. The incident occurred while the area was being cleared after offloading crude oil the day before.

Actual consequence
The deck operator suffered serious head injuries.

Potential consequences
Under different circumstances, the deck operator could have suffered several serious injuries or died.

Direct cause
The PSA’s investigation concludes that the socket termination on the wire rope got caught in the guide roller in front of the winch, which caused it to come under considerable strain. Findings at the site and witness statements indicate that the cast socket termination on the rope came free, and that the rope struck the deck operator on the head.

Findings by the investigation
Several regulatory breaches have been identified, including a lack of or inadequate barriers which could otherwise have prevented the serious incident. A number of underlying technical, organisational and operational causes have thereby contributed to allowing this accident to happen.

The investigation has found deficiencies in governing documents, inadequate management of risk and competence, and a lack of clarity in roles and  responsibilities. Examples include design faults and deficiencies in the winch and guide roller, a lack of risk assessment for the work operation, insufficient competence and inadequate training in using the equipment. In addition, user manuals were missing and no conformity measurements had been made of the equipment being used.          

Nonconformities have been identified relating to follow-up of technical conditions, identification of operational risk, governing documents, work processes, worker participation, commissioning work before start-up and operation, material handling plan, roles and responsibilities and competence.

On the basis of the findings in its investigation, the PSA has given Eni notice of the following order:
Pursuant to section 69 of the framework regulations on administrative decisions, see sections 17 of the framework regulations on the duty to establish, follow up and further develop a management system, and 6, 8, 15 and 22 of the management regulations on the management of health, safety and the environment, internal requirements, information and handling of nonconformities respectively, Eni Norge AS is ordered to:

  1. systematically identify and review all lifting equipment and winches used for material handling on board and assess measures for further use or possibly ceasing to use this equipment
  2. present a binding and timetabled plan with a deadline for implementing measures based on findings from the review
  3. present a plan for permanent resolution of design deficiencies in the loading hose with regard to twisting, and describe risk-reducing measures until a permanent solution is in place.

The deadline for complying with this order is 13 February 2017. We must be notified when the order has been complied with.

Explanation of the terms "order" and "notification of order"
An order is an administrative decision made pursuant to the regulations. Before we issue an order, we generally send a "notification of order" to the affected companies.

A notification of order is neither an instrument nor a notice of sanctions, but a step in the PSA's case processing in which we request the party to assess the factual basis. The notification is only the first step before an administrative decision is made.

An order is a strongly preventive instrument which is legally binding on the recipient.

Øyvind Midttun, Press contact
Email: oyvind.midttun@ptil.no | +47 51 87 34 77