BSEE: Crewman fell to his death through faulty grating

  • Safety Flash
  • Published on 16 April 2021
  • Generated on 3 April 2025
  • IMCA SF 11/21
  • 2 minute 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

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

Pre-Incident photograph of hazardous grating section

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

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 person standing near the open hole

Post-incident photograph of hazardous grating section

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 fulfil 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.

Actions

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.

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