The notice of order was given 7 March 2024.

Havtil decided on 24 April 2023 to investigate the incident, and has also provided technical support for the police inquiry into what happened.

The incident occurred during splitting of a blind hub on a new production pipeline, when the system turned out not to be fully depressurised. Pressure in the pipeline threw the 34-kg hub about 1.5 metres into the air. It then hit a person on the way down, breaking their nose and jaw.

In addition, a 2.15-kg sealing ring fell to the level below and hit a person there, without causing a personal injury.

Seven people were present in the immediate vicinity during splitting of the blind hub on the hydrocarbon system (production pipeline). One person was also present on the level below.

The subsequent gas leak was of brief duration and totalled about 2.4 kg.


Under slightly different circumstances, the incident had the potential to become a fatal accident.

Identified lessons learnt

The investigation has identified lessons related to the following.

  • The work permit for splitting the hydrogen system was applied for, processed, approved and activated with an attached isolation plan which was not relevant for the job to be done.

    This plan was not looked at in connection with safety-clearance of the work. That could happen because the plan was contained in a file attached to the work permit, which remained unopened throughout processing of the permit. It had a file name which could suggest it was relevant for the job concerned.

    The incident would have been avoided had the isolation plan attached to the work permit been checked before the latter was activated. This demonstrates the importance of complying with established procedures.

  • When verifying that the system was depressurised before splitting, the operators did not notice that the valve they chose to open incorporated a check valve.

    This meant they erroneously concluded that the system was depressurised. The design of the valve used for verification differs from other valves used for chemical injection on the facility, but this was unknown to the relevant personnel.

    Where a facility has been in operation for a long time and modified by the installation of equipment with a new design, training and documentation are important factors for ensuring adequate knowledge of the equipment.

Nonconformities and improvement points

The investigation identified four nonconformities from the regulations in connection with the incident.

  • inadequate safety-clearance of activities
  • inadequate information transfer at shift and crew changes
  • lack of information for the relevant users
  • planning of the work failed to identify important contributors to ignition source risk.

Furthermore, the investigation team identified one condition it has chosen to categorise as an improvement point, which relates to lack of capacity for executing planned activities.


The investigation has found serious breaches of the regulations, and Equinor has been given the following order:

Pursuant to section 69 of the framework regulations on administrative decisions, we order Equinor FLX to do the following.

  • Identify measures and establish a plan for implementing measures to ensure compliance with the requirements for safety-clearance of activities, see section 11.1.1 of the report, see section 30 of the activities regulations on safety-clearance of activities, see section 22, paragraphs 2 and 4 of the management regulations on handling of nonconformities.

  • Identify measures and establish a plan for implementing measures to ensure necessary transfer of information on the status of isolation plans at shift and crew changes, see section 11.1.2 of the report, see section 32 of the activities regulations on transfer of information at shift and crew changes, see section 22, paragraphs 2 and 4 of the management regulations on handling of nonconformities.

  • Conduct an internal verification to investigate whether the measures identified under sections 1 and 2 have had the desired effect, see section 22, paragraph 2, point 2 of the management regulations.

What happens now?

The deadline for complying is 1 June 2024 for sections 1 and 2 of the order and 1 June 2025 for section 3. Havtil must be notified when the individual points in the order have been complied with.