How Offshore Incident Investigation and Reporting Is Done Professionals
My Background and Why I Take Incident Investigation Here
To start this guideline first I want to put on paper a summary of my experience and background and what enforces me to give you this guideline.
I have been working in Health, Safety and Environment since 2007. I started my career in shipyards as HSE Engineer, spending almost six years at Daewoo Heavy Industries where I reach the role as HSE Coordinator for the department which was responsible mainly with the management system of HSE, risk assessments, procedures, incidents investigations and reporting, a working place where heavy lifts, hot works, confined spaces, and production pressure exist simultaneously, every single day, no exceptions.
Later, I took the decision that is time to change the environment of my career and I moved into the offshore oil and gas industry and the maritime sector, where the risks are fewer in number but far higher in consequence. Major accident hazards, dynamic positioning, high-energy systems, isolation failures, and complex SIMOPS are normal offshore realities.
After nearly two decades in HSE, I can say this with confidence:
Offshore incident investigation and reporting is one of the most powerful safety tool we have-if it is done correctly and accountability.
This is not just and article, it is a guideline for you, to help you in the investigation and reporting process, based on real operations, real failures, and real learning.
What Offshore Incident Investigation and Reporting Means to Me
For me, offshore incident investigation and reporting has one purpose only:
To prevent the next accident, not to explain the last one.
A proffesional investigation:
- explains what happened
- exposes why it made sense at the time
- and forces changes where risk controls actually failed
A poor investigation produces a report.
A good investigation produces change.
This thinking is fully aligned with the principles promoted by the Health and Safety Executive, for me is the best authority in health and safety, which consistently emphasises learning, system failure, and prevention over blame.
The Leading Causes of Accidents in the Offshore Industry
Across shipyards, offshore platforms, and vessels, I have seen patterns repeat themselves. These are not my opinions-they are the same patterns identified by HSE investigations.
1. Line of Fire and Stored Energy
One of the most consistent causes of serious offshore accidents is exposure to line of fire, 70 % of the incident occurs due to breaching the LoF:
- suspended loads
- pressurised systems
- rotating equipment
- stored mechanical or hydraulic energy
HSE investigations repeatedly show that workers are injured not because they “did something stupid,” but because barriers failed to keep them out of harm’s way.
Typical HSE findings include:
- poor task planning
- inadequate exclusion zones
- last-minute changes not reassessed
- weak supervision during critical phases
2. Isolation and Energy Control Failures
Isolation failures remain a one of the main root in offshore incidents.
Examples I have personally investigated include:
- electrical systems assumed dead but not proven
- hydraulic pressure reintroduced during maintenance
- inadequate lock-out / tag-out verification
- simultaneous work conflicting with isolations
HSE investigations consistently link these events to:
- poor isolation standards
- inadequate training and competence
- and poor management of PTW and weak control of permit-to-work interfaces
3. SIMOPS and Poor Interface Management
SIMOPS is where offshore investigations become complex.
Many serious incidents occur at the interface between activities:
- lifting over live systems
- maintenance during marine operations
- construction near operating plant
- 500 m zone operations in field
HSE examples show that SIMOPS accidents are rarely caused by a single task—but by gaps between tasks.
4. Procedural Drift and Normalisation of Deviation
Another common theme I see-and one highlighted in HSE investigations-is procedures that exist but are no longer followed.
Not because people are reckless, but because:
- the procedure no longer reflects reality
- shortcuts have become “normal”
- supervision has adapted to production pressure
This is where investigation must move beyond the workforce and into organisational decision-making.
The First Hour After an Offshore Incident
From experience, the first hour decides the quality of the investigation.
I always apply the same structure:
Stop – Stabilise – Secure – Notify
Stop
- Stop the task immediately when is safe to do so
- Apply stop-work authority
- Prevent escalation of the incident, inform the others who might be affected
Stabilise
- Isolate energy
- Secure loads
- Control SIMOPS
- Protect people and assets
Secure
- Preserve the scene
- Control access
- Start a factual event log immediately
Notify
- Inform the top management on site
- Escalate in maximum 24 hours internally
- Assess regulatory reporting, as per the law and internal procedures
- Notify authorities where required
Once the scene is disturbed, facts are lost forever.
Evidence: Base of Every Good Investigation
In offshore incident investigation and reporting, evidence is everything.
Evidence includes:
- scene condition and configuration,
- permits and isolations as found
- risk assessments and procedures
- maintenance and defect history
- DP logs, alarms, CCTV
- radio communications
- witness accounts
I treat every document, photo, and log as material evidence from the moment an incident occurs.
HSE guidance is clear that investigations must be systematic, evidence-based, and capable of external scrutiny.
Investigation Roles – Clearly Defined and Experience Based
Depending on severity and potential, I define investigation roles very clearly. This avoids confusion, bias, and weak conclusions at the end of the investigation.
1. Case Owner (Company Senior Role)
Who should be this:
- Offshore Project Manager
- Offshore Installation Manager
- Vessel Master
- Senior Onshore Manager (for high-potential events)
Why:
This person has the authority to allocate resources and enforce change. Without senior ownership, investigations stall.
2. Lead Investigator
Who should be this:
- Experienced HSE professional, manager of the HSE department or corporate senior
- Trained incident investigator (Senior investigator training preferred)
- Independent from direct task execution
Why:
Investigation competence is not the same as technical expertise. This role requires structure, objectivity, and method.
3. HSE Advisor/ Investigation Facilitator
Who should be this:
Why:
This role controls bias, ensures method consistency, and maintains alignment with HSE expectations.
4. Technical Specialists
Who should be this:
- DP engineers
- Electrical or mechanical engineers
- Lifting or marine specialists
Why:
They explain how systems work, not what caused the incident. They support the investigation-they do not lead it.
5. Evidence Keeper / Clerical Staff
Who should be this:
- HSE or QA personnel – usually is the HSE Advisor intros role but also it can be supported by the technical clerk personnel
Why:
Evidence integrity is critical, especially when regulators or insurers are involved.
Investigation Methods and Techniques I Use
Over the years, I have learned that simple, structured methods work best offshore and maritime industry.
Initial Information
In most of the situation, there is investigation report format in place already, or if not there is a report format required by law, like RIDDOR in UK, by Health and Safety Executive.
On the start part of the report you have to fill several informations like:
- Date of incident occurrence
- Time
- Date of reporting
- Who is owner of the report
- Involved parties
Timeline Reconstruction
A factual, validated timeline built from:
- logs
- data
- and witness accounts
No opinions. No assumptions. The time line describing the moments, in a timely manner, before – during – after the incident, to be able to get a clear understanding of the contextual situation.
Incident Classification and Consequences
The incidents shall be classified as:
- Near Miss
- Accident
- Work related/ Not Work Related
- Transportation/ At Work
The severity of the incident for Real and Potential Outcomes:
- First Aid
- Medical Treatment
- Work Restricted
- Lost Time Incident
- Fatality
- Multiple Fatalities
- Asset Damage
- Environmental Pollution
Brief Description and Immediate Actions
Here is made a summary of the incident, very brief description of what happened, and immediate actions taken at the moment of the incident. Here are not presented any conclusions, corrective actions.
Barrier-Based Thinking
I always ask:
- What barrier should have prevented this?
- Why did it fail or not exist?
- What controls where in place?
This moves investigations away from blaming people and toward strengthening our safety controls.
Witness Interviews
I conduct interviews never alone, always in a committee way. The interviews are done:
- after people are safe
- without blame language
- focused on understanding decisions and conditions
Poor interviews destroy trust and learning. Some times the interviews can be extended to more then one time, for further clarifications as the investigation progress.
Interviews can be done as well via Teams or any other online platform, if the witness is not available any longer at the work place.
Injured Person/ Asset Damages/ Environmental Pollution Details
As applicable, here are presented the details over the affected parts by the incident occurence.
Detailed Description of the Investigation Report
Here is clearly presented, a step by step, investigation findings and the conclusions of the investigations
- starting from initial stage
- going through the moment of occurrence
- final conclusions of the investigation
- consequences of the incident (injury to personnel, asset damage, environmental)
Immediate, Underlying, and Root Cause Analysis
This structure forces the investigation to move:
- from what failed
- to why it failed
- to why the organisation allowed it
This aligns directly with HSE investigation principles. This is the one of the most important parts to have a clear picture of what happened – why did happened – how to be prevented for the future.
Corrective Actions and Follow-Up
In order to avoid similar incidents to happen again a detailed action plan must be in place.
Sufficient corrective actions shall be implemented for each of the immediate, underlying, and root cause
- Cause description
- Corrective actions
- Owner of the corrective actions
- Deadline for implementation
Final Closure, Approval and Distribution
The report draft once is completed, shall be reviewed together with all team involved in the investigation.
The final report shall be submitted first for approval at the management level.
Once approved the report is distributed to all interested parties and archived for future evidences.
Many companies this days are using softwares to ease such process, where all is filled up and submitted electronically.
Training That Actually Improves Investigation Skills
Experience alone is not enough.
The most effective investigators I’ve worked with had structured training, such as those provided by Kelvin TOP-SET, which focus on:
- investigation planning
- evidence analysis
- root cause techniques
- and writing actionable recommendations
Good training improves:
- investigation quality
- confidence
- and credibility with regulators
Refresher training is equally important to prevent method drift and bias.
Why I Still Work in This Field With Passion Even After Almost 20 Years
I have worked in:
- shipyards
- offshore oil and gas
- maritime operations
I have seen serious accidents, near misses that could have killed people, and investigations that truly changed how work was done.
I truly believe that most incidents can be prevented and it is in our hands the safe way to go.
A good topic that we can approach is related to Human Performances, brought to the light by the International Association of Oil and Gas Producers, which make continuous efforts to improve the health and safety into the oil and gas industry.
Human Performances are focused on 5 Principles:
- Error is Normal
- Blame Fixes Nothing
- Context Drives Behaviour
- Learning is Vital
- How Leaders (You) Respond Matters
With my background and experience, I can provide practical support, guidance, and structure in this field-because I have lived it, learned from it, and still care deeply about doing it right.
Source
This article is based on my professional experience that I want to share with you, also it has sourced the Health and Safety Executive and IMCA available reports, and IOGP.
If you need advice and guidance and how to implement a high level HSE Management System, please do not hesitate to contact HSE Smart Solutions.
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