Inadequate communication was responsible for a fatal accident on Statoil's Heidrun field, the internal inquiry report has concluded.
Børre Dalstein, a 27-year-old roughneck on the Norwegian Sea platform, was crushed while working to free drill pipe at the top of the derrick early on 14 February. He was flown to hospital in Trondheim, but his life could not be saved.
"The scope of the job had not been properly explained to those involved," the report concludes.
Dalstein was lifted up to the top of the derrick to remove a stand of drill pipe, apparently without the person operating the pipehandling equipment being informed.
While the roughneck was working to secure the remaining stands, the machine operator started preparations to remove one of them. That appears to have crushed Dalstein between the pipe hoist and the stacked pipe.
Bad weather with very strong winds meant that a helicopter was unable to land on the platform until eight hours after the accident.
The inquiry commission suggests that all use of moveable equipment in the derrick must be banned while somebody is in the personnel winch.
It also calls for a discussion on whether risky jobs should be undertaken on offshore platforms when the weather is too bad for a helicopter to land.