How NOPSEMA investigates – and why it matters
When there is a serious accident or dangerous occurrence at an offshore energy facility, the public response is understandable: something went wrong and the regulator should act. At NOPSEMA, we do act – and we take that responsibility seriously.
But what a formal regulatory investigation actually involves, and why it takes the time it does, is often misunderstood. This article sheds light on the investigation process and notable improvements to NOPSEMA’s investigative capacity.
Two things happening at once
When NOPSEMA becomes aware of a serious incident or suspected non-compliance, two separate but parallel processes begin.
The first is an immediate response to assess and manage any ongoing risk. NOPSEMA inspectors can attend facilities, assess conditions, issue notices and directions, and require operators to take specific action. These tools are powerful and can be deployed quickly – even while an investigation is underway. The aim is to ensure the immediate risk is properly managed on the ground.
The second process is a formal investigation. This serves a different purpose and operates in a different way. An investigation is not the mechanism used to control immediate risk on site. Instead, it is a structured, evidence‑based process designed to establish root causes and contributing factors including establishing what happened and how it happened. Once the evidence has been gathered and analysed, consideration can then be given to whether an enforcement option is warranted. This may include a range of actions, such as issuing an improvement notice or general direction, entering into an enforceable undertaking, or pursuing a prosecution or civil penalty through the courts.
These two functions are deliberately separate but usually run at the same time. Understanding how they differ is essential to understanding why investigations take time.
It is also important to note that not all investigations are lengthy or very complex. NOPSEMA conducts many smaller investigations each year, which due to lower complexity or seriousness of consequence are managed quickly and efficiently within much shorter timeframes.
Why thorough investigations take time
A formal regulatory investigation in the offshore energy sector is a complex undertaking. Incident sites are often remote and difficult to access, meaning extensive planning and preparation is required before heading offshore. Once on a facility, investigators must work with whatever equipment and materials they have brought with them – there is no opportunity to “pop down to the local hardware store” if some critical equipment is not available to the investigators.
Key witnesses may also be based or reside across Australia or even in different countries, often working fly‑in fly‑out rosters that complicate the scheduling of interviews. Interviews generally follow a deliberate sequence to ensure investigators have the necessary facts from one witness before speaking with the next. As new evidence emerges, it is common for key witnesses to be interviewed more than once. This careful, structured approach is essential to obtaining the best and most reliable evidence.
Physical evidence – such as mechanical components, electronic systems or environmental samples – often requires specialist analysis undertaken by external subject‑matter experts (SMEs). The extent of this technical work varies from case to case, and the expertise needed is not always available locally. In some circumstances, items must be sent interstate or overseas for testing. Engaging the right expertise early is essential to understanding what happened and why.
Documentary evidence may also be extensive. Employment records, fitness‑for‑work assessments, safety procedures, maintenance histories, technical specifications, communications and training records all need to be gathered, verified and cross‑referenced as new information emerges. Ensuring the completeness and integrity of this material is a significant part of the investigative process. This may also involve more than one company where contractors and subcontractors are involved.
Expert witnesses are frequently required to establish what was technically feasible, what a duty holder knew or ought to have known, and what caused a specific failure. Identifying the right expertise, confirming independence, and obtaining expert reports is a detailed and time‑consuming process. Many SMEs are located overseas and are in high demand, making them difficult to engage. Depending on the complexity of the matter, NOPSEMA may need to engage several SMEs to assist the investigation by providing independent technical analysis.
These SMEs must be genuinely independent. Their role is to assist the court where required, not to support the investigation, and they must be provided with the full evidentiary picture so they can form their own informed view. This process cannot be rushed without compromising the quality and credibility of the outcome.
Throughout all of this, investigators must operate strictly within the legal framework established by Parliament. Evidence must be gathered, documented and preserved to a standard that can withstand rigorous scrutiny if the matter proceeds to court. This is not bureaucratic caution – it is the foundation of any credible enforcement action. It is common for investigators to work with both internal and external legal advisers to ensure NOPSEMA is acting lawfully and to progress the investigation appropriately. Legal teams representing duty holders also frequently raise queries that must be considered and responded to in a timely and accurate manner.
Why quality matters beyond the individual case
The quality of an investigation directly shapes how well NOPSEMA can identify root causes, contributing factors and meaningful lessons. For lessons to be credible and useful across industry, the underlying evidence must be thorough and reliable. These lessons may come from the incident itself, from similar incidents in Australia or overseas, or through engagement with industry bodies that hold specialist knowledge.
When an incident is serious and may result in prosecution, the standard of the investigation becomes even more important. A well‑prepared brief of evidence, supported by solid expert analysis, provides the court with a clear and dependable basis for decision‑making. Before recommending prosecution, NOPSEMA must be confident a breach has occurred. The Commonwealth Director of Public Prosecutions (CDPP) must also be satisfied that there is sufficient evidence and that prosecution is in the public interest. This process often requires detailed engagement with the CDPP over an extended period.
Strong, comprehensive evidence enables enforcement outcomes that reflect the seriousness of the conduct and the risks involved. Weak or incomplete investigations, by contrast, can lead to outcomes that fail to capture the gravity of the incident – and, over time, this can affect expectations and precedents across the regulatory system.
For NOPSEMA, this is not theoretical. The offshore oil and gas industry operates in some of Australia’s most challenging environments, where the consequences of safety failures can be severe. High‑quality, credible investigations not only support the identification of lessons but also underpin effective and appropriate enforcement action. Together, these elements help maintain the strong safety culture the industry depends on.
Building an enhanced investigations function
Over the past two years, NOPSEMA has invested heavily in strengthening its investigative capability and that investment is already delivering results.
Where investigations were once carried out by regulatory inspectors drawing primarily on their compliance experience, NOPSEMA now has a dedicated team of specialist investigators with deep expertise in complex evidence‑gathering, brief preparation and enforcement. These investigators bring skills and knowledge the organisation has not previously held, enabling a far more sophisticated approach to investigations.
Policies and procedures have been reviewed and updated, and the use of investigative powers has been strengthened. From the initial triage and scoping of a matter through to identifying lessons or preparing a comprehensive brief of evidence, NOPSEMA’s investigative framework has been rebuilt on a more rigorous, systematic foundation.
NOPSEMA Chief Executive Officer Sue McCarrey said the transformation reflects a deliberate strategic choice.
“Effective investigation is one of the most important things a regulator can do for education, accountability, deterrence and safety culture within the industry we regulate. Over the past few years we have built a genuinely specialist investigations function: new people, new processes, a thorough review of our powers and a much more sophisticated approach to complex evidence. We are a more capable regulator than we were and that capability is now being put to work,” Ms McCarrey said.
“This matters for timeliness as well as quality. With a specialist team, clearer processes and greater capacity, NOPSEMA is now targeting a two‑year maximum timeframe for investigations. This reflects both our commitment to accountability and our recognition that prolonged investigations serve no one well.
“We are not complacent about the time our investigations take. Industry deserves to know that when NOPSEMA investigates, we do it thoroughly and we do it as efficiently as we can. Two years is our target. We are building the capability to meet it consistently,” she said.
A final group of significant legacy investigations is now nearing completion. As these conclude, NOPSEMA’s investigations program is moving into a new phase – more focused, more efficient and better resourced to respond to new matters quickly and thoroughly.
What this means for industry
For operators and duty holders, the message is clear: the announcement of a formal investigation does not mean NOPSEMA’s focus shifts away from the facility and toward the courts. NOPSEMA’s immediate priority is always to ensure that risks are being properly managed on site. At the same time, investigators work to understand the circumstances of the incident and identify any lessons that could help prevent a similar occurrence across industry. This is the key focus for investigations.
NOPSEMA will also work with duty holders to bring them back into compliance, and where appropriate, may use enforcement powers to achieve this. Non‑compliance with notices and directions is a serious matter. This type of conduct is exactly what can lead to more significant enforcement action when an investigation is reviewed.
The offshore industry has made genuine progress in safety culture over many years, and NOPSEMA’s relationship with industry is built on a shared commitment to protecting workers, the environment and the communities that depend on both. Investigations are part of that relationship – not a departure from it.
If serious incidents occur, thorough and credible investigations are how lessons are identified and accountability is established. They provide the foundation for preventing further occurrences and ensuring duty holders return to compliance where standards have not been met.
NOPSEMA has a range of regulatory tools available, and a robust investigation ensures the right tool is used for each situation. Investigations also signal to industry what the expected standards are, and what the consequences may be when those standards are not upheld.
That is what NOPSEMA’s investigations are for – and that is why getting them right is worth the time it takes.