Norway's offshore safety authority PSA Norway has completed its investigation into the cylinder burst incident that happened aboard Equinor's Heimdal platform off Norway in November 2019.
The incident, in which two workers were seriously injured, occurred while filling (pressurizing) a 3.4-liter nitrogen gas cylinder, which formed part of the fire extinguishing system on the platform and was to be pressurized to 200 bar using a booster pump.
During the operation, the cylinder burst and broke into several pieces. A three-strong work team was present, and two of its members were seriously injured.
"The actual consequence of the incident was that two people were badly hurt, and one suffered life-threatening injuries. Both spent a long period on sick leave...Under slightly different circumstances, the incident had the potential to become a fatal accident," the PSA Norway said Thursday.
The PSA said that the direct cause of the incident was that the nitrogen gas cylinder is likely to have been exposed to a significantly higher pressure than it was designed to cope with.
The PSA said its investigation had found serious breaches in regulations. The safety body highlighted inadequate safety-clearance of activities; lack of barriers against overpressure lack of competence; inadequate planning and risk assessment; lack of procedures and routines.
The PSA gave Equinor a notice of order under which the company has to make sure that similar activities are planned and executed in such a way that those who participate in the activity are not injured and that the probability of human error is reduced.
That involves taking the measures required to ensure adequate competence in using this type of tool, and ensuring that the risk is known in all relevant parts of the organization.
Also, Equinor has to ensure that knowledge about and lessons learned from the incident is communicated in a systematic way to the whole company.
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