The incident occurred during turnaround TA25 at the refinery. A work crew had lifted a heat exchanger for inspection and was preparing for the next lift. As the lifting gear was being hoisted up, a hook became caught on a bolt that had been left in the flange on the approximately 7.5-tonne heat exchanger.

The heat exchanger was accidentally lifted, swung sideways and struck a slinger, who is responsible for attaching and releasing the load during crane lifts. The slinger was positioned between two heat exchangers and was crushed between them. The person concerned was critically injured and died shortly afterwards.

Several people were in close proximity to the heat exchanger while it was still moving, in an attempt to provide assistance following the accident. Under slightly different circumstances, several people could therefore have been injured.

Direct and underlying causes

Havtil's investigation has identified a number of factors which collectively contributed to the incident.

The direct cause of the accident was that a hook became caught on a bolt, causing the heat exchanger to be lifted unintentionally.

The investigation also showed that several underlying factors may have contributed to the incident. Havtil has identified weaknesses throughout the entire chain, from planning and risk assessment to competence, implementation and follow-up of the work in the field. Previous experience was not utilised effectively, and known safety challenges prior to the accident were not addressed adequately.

Lessons must be learnt

“This was a serious incident with a tragic outcome. "A young man lost his life and many people were affected," said Havtil’s Director General Sigve Knudsen.

“The accident occurred during a turnaround. During turnarounds, activity levels are high, many participants are present at the facility, and there are numerous interfaces between companies and groups of personnel. This makes risk management particularly challenging. Risks must be identified at an early stage and monitored.

“Our investigation shows that the incident must be understood in light of numerous factors relating to the planning, execution and follow-up of the work. We really need to learn from this in order to prevent anything like this from ever happening again.

Non-conformities

The investigation revealed six non-conformities at Equinor and three non-conformities at Crane Norway Vest.

The non-conformities at Equinor are linked to:

  • Materials handling plan
  • Risk management for lifting operations
  • Follow-up
  • Operational management
  • Planning
  • Inadequate radio communication of PA announcements

The non-conformities at Crane Norway Vest are linked to:

  • Information
  • Lifting operations
  • Competence

Orders

Based on the observations made during the investigation, we have issued the following orders to Equinor and Crane Norway Vest:

Order to Equinor
Pursuant to the Framework Regulations, Section 69 concerning administrative decisions, Equinor Mongstad is ordered to:

  1. Systematically review and map lifting equipment, equipment and machinery associated with materials handling, and implement measures identified in connection with the review and mapping to ensure safe use, with reference to the Framework Regulations, Section 17 concerning the duty to establish, follow up and further develop a management system, and the Technical and Operational Regulations, Section 11 concerning materials handling and transport routes, access and evacuation routes, with reference to section 9.1.1 of the report.

  2. systematically review and map all areas and systems linked to materials handling in order to reduce risk, and assess compliance with requirements for safe and prudent materials handling, with reference to the Management Regulations, Section 4 concerning risk reduction, and the Technical and Operational Regulations, Section 43 concerning critical activities, with reference to the guidelines, litera g, with reference to section 9.1.2 of the report.

  3. establish a materials handling plan that ensures that the handling of equipment and machinery that need to be lifted and transported is performed in a safe and prudent manner, with reference to the Technical and Operational Regulations, Section 11 concerning materials handling and transport routes, access and evacuation routes, and the Technical and Operational Regulations, Section 62 concerning lifting operations, first paragraph, with reference to sections 9.1.1 and 9.1.2 of the report.

We request that Equinor present a time-delimited schedule by 18 November 2026

The deadline for complying with the order is 30 April 2027.

Havtil is to be notified when the order has been complied with, and Equinor shall at the same time submit established procedures and documentation in respect of measures taken to comply with the order, with reference to the Framework Regulations, Section 23 second paragraph.

Order to Crane Norway Vest
Pursuant to the Framework Regulations, Section 69 concerning administrative decisions, Crane Norway Vest AS is ordered to:

  1. Systematically review and map the execution of lifting operations by both the company’s own employees and hired workers. This involves, inter alia, ensuring that the necessary information is collected, processed and communicated to relevant users so that lifting operations are carried out in a safe and prudent manner, with reference to the Management Regulations, Section 15 concerning information, and the Technical and Operational Regulations, Section 62 concerning lifting operations, with reference to sections 9.2.1 and 9.2.2 of the report.

  2. Systematically review and map whether the company’s own employees and hired workers possess the necessary competence to perform lifting operations, cf. the Technical and Operational Regulations, Section 50 concerning competence, and the Regulations concerning the Performance of Work, Section 10-4 concerning requirements for equipment-specific training, with reference to section 9.2.3 of the report.

  3. Develop procedures and measures to ensure that personnel possess the necessary competence at all times to carry out lifting operations, with reference to the Technical and Operational Regulations, Section 50 concerning competence and Section 62 concerning lifting operations. This order applies to both training requirements and equipment-specific requirements relating to use and execution, with reference to the Regulations concerning the Performance of Work, Section 10-2 on the requirement for documented safety training when using work equipment and Section 10-4 on requirements relating to equipment-specific training; with reference to sections 9.2.2 and 9.2.3 of the report.

The deadline for complying with the order is 23 February 2027.

Havtil is to be notified when the order has been complied with, and Crane Norway Vest AS shall at the same time submit established procedures and documentation in respect of measures taken to comply with the order, with reference to the Framework Regulations, Section 23 second paragraph.

English version of the investigation report is pending.