This incident occurred in connection with a work operation in the cracker facility at the Mongstad refinery in Vestland county, where Equinor is the operator.

Following maintenance on one of the CO boilers, acid residues were to be drained from a low point. An unexpected escape of steam then occurred. The steam was at a temperature of 240°C and a pressure of 36 barg.

Two operators were on a scaffolding at the leak point. The steam pressure and temperature, combined with a high noise level, meant that one of the operators had problems evacuating the site safely. He chose to escape over the edge of the scaffolding and fell/slid about four-five metres to the level below.

Actual and potential consequences

One person was sent to a local accident and emergency department, which found minor injuries to his upper body as well as a sprained ankle.

Under slightly different circumstances, the incident could have led to serious personal injury or death.  

Direct and underlying causes

The direct cause of the incident is that an operator fell/slid between pipes down to the level below (about four-five metres) while trying to evacuate from an area with steam.

Underlying causes relate primarily to:

  • supervision of work and risk management
  • compliance with procedures/requirements
  • constricted workplace and difficult access.

Nonconformities and improvement points

The investigation has identified the following nonconformities:

  • compliance with the company’s own procedures/requirements
  • risk management when planning and executing work
  • transfer of information following a personnel change in the work team.

A condition has also been observed which is categorised as an improvement point. This applies to expertise and training.

What happens now?

The PSA’s investigation has been completed. Equinor has been asked to explain how the nonconformities will be dealt with, and to give the PSA its assessment of the improvement point observed. The deadline for these responses has been set to 8 January 2021.