During the installation of a scaffolding, a person fell 23.5 metres from the structure to a concrete floor and suffered serious injuries. Under slightly different circumstances, the fall would have caused the death of the person involved.

Direct causes

The direct cause of the incident was that the hook on the ledger which the injured party had attached his fall-arrest safety harness to came loose from the standard at one end of the scaffolding. He lost his balance on the ledger he was standing on, causing him to fall backwards so that the hook at the other end of the ledger holding his harness bent and detached from the standard.

Underlying causes

The investigation has found that understanding by those involved of the job’s complexity and the factors which have influenced it led to inadequate planning, organisation and execution of the scaffolding activity. This was a contributory cause of the incident, along with the contract format, a high workload and stress.

Understanding the Norwegian safety regime and making provision for the necessary capacity and expertise are two important elements which are also regarded as contributory causes by this investigation.

Order to Beerenberg – January 2023

In connection with the investigation, Beerenberg Services AS (BBS) was given an order by the PSA on 27 January 2023 to halt all installation, disassembly and alteration of scaffolding at Mongstad. BBS complied with the order and confirmed its implementation on 30 January 2023.

Nonconformities – Equinor

The investigation identified nonconformities related to:

  • inadequate risk assessment
  • follow-up of other participants
  • failure to ensure conformity between its own emergency plans and response, and those of other participants
  • emergency response plan does not cover rescue at a height.

The PSA also observed two conditions it has chosen to categorise as improvement points:

  • inadequate manning in the health and safety service
  • inadequate emergency drills and training involving the ISS contractor/BBS.

Nonconformities – BBS

The investigation identified nonconformities related to:

  • risk assessment and organisation of the work
  • organisation and execution of maintenance
  • expertise
  • communication of information
  • self-rescue, fall rescue and rescue at a height are not planned and prepared for, or described in the emergency response plan
  • emergency drills and training are not carried out systematically for BBS personnel
  • management of the psychosocial working environment.


The investigation has identified serious breaches of the regulations, see chapter 9.1 of the report, and the PSA has given Equinor the following order.

  1. Pursuant to section 69 of the framework regulations on administrative decisions, see sections 4 and 8 of the management regulations on risk reduction and internal requirements respectively, Equinor Mongstad is ordered to do the following.

    Conduct an integrated and systematic overall risk assessment of work at a height in order to ensure that risk factors in the work are followed up by its own organisation and by contractors, including ensuring that collective safety measures are preferred over measures directed at individuals, and apply lessons learnt from similar incidents in work on risk reduction.

  2. Pursuant to section 69 of the framework regulations on administrative decisions, see sections 21 and 15 of the management regulations on follow-up and information respectively as well as section 50 of the technical and operational regulations on competence, Equinor Mongstad is ordered to do the following.

    Conduct an integrated and systematic review of management systems at contractors carrying out work at a height to ensure the necessary competence and compliance with the regulations and Equinor’s internal requirements.

The deadline for meeting the order is 1 October 2023.