In connection with a planned six-monthly valve test, a needle valve detached from the top cover of a valve tree, striking an employee in the face. The needle valve was under a pressure of 80 bar, and the force of the impact resulted in serious facial injury.


The actual consequence of the incident was a serious personal injury. Marginally different circumstances could have resulted in death.

Long-term injuries caused by exposure to hazardous gases and noise have not been ascertained but have been identified as a possible risk.

The well was left without a plug in its top cover for several hours, during which time gas was observed above the valve tree. It cannot be ruled out that a gas cloud formed in the area, nor that parts of it were in an area exposed to explosion risk.

Direct cause

The direct cause of the incident was that the needle valve detached from the valve tree as a result of corrosion of the lowermost threaded part of the valve housing. The needle valve was under a pressure of 80 bar when the employee began the work.

Identified lessons learned

The investigation has identified several lessons learned linked to organisation, verifications and internal monitoring, technical integrity, emergency response and challenges associated with the acquisition and handover of a petroleum facility.

The findings of the investigation underline the importance of obtaining a complete overview of the technical condition status of a petroleum facility when a new operator assumes responsibility. This includes creating consistent procedures and a management system capable of handling operations.


The investigation identified seven non-conformities in relation to regulations connected with the incident. These involve:

  • Lack of verifications to demonstrate compliance with the HSE regulations
  • Inadequate maintenance and overview of technical integrity
  • Roles and responsibilities
  • Inadequate procedures
  • Organisation of work
  • Inadequate emergency management training and drills
  • Management of hazard and accident situations

In addition, we observed one factor categorises as an improvement point regarding inadequate recording of exposure to hydrocarbons.


The investigation has confirmed serious breaches of the regulations and OKEA is hereby given the following order:
Pursuant to Section 69 of the Framework Regulations relating to administrative decisions, cf. Section 6 of the Management Regulations relating to health, safety and environmental management, OKEA is required to:

  • assess whether the Annual Audit Plan for Brage is adequate for compliance with the HSE regulations and establish initiatives for compliance with the verification plan, see nonconformity 9.1
  • identify why Platform Internal Verification (PIV) activities were not implemented according to plans. Establish initiatives to ensure compliance with the PIV, see nonconformity 9.1
  • obtain an overview of the technical state of the needle valves on the valve trees and ensure that routines are in place for monitoring and maintaining them, see nonconformity 9.2
  • identify and correct inadequacies in the governance documents and management system for work connected with pressurised systems, see nonconformity 9.4

What happens now?

The report documents proven nonconformities in addition to those which form the basis for the notification of this order. We request an explanation as to how the nonconformities will be addressed.

We request a status meeting with OKEA before the summer regarding plans for closing nonconformities and OKEA's response to this order. We request your written feedback regarding the rectification of non-conformities by 15 September 2024.