The following report, submitted by a company to CHIRP for the benefit of the industry, provides a good example of how these incidents should be treated.
Contractor was discovered hot working in the vicinity of the vessel’s steering compartment whilst aft mooring hydraulic system was in operation. Had there been a hydraulic leak there could have potentially been a fire and/or explosion. The conflicting work had been discussed at the daily work planning meeting, however it had been misunderstood by the contractor foreman.
What went well:
- Prior to the incident the daily planning meetings had been effective in ensuring all involved were aware of work planned for the day,
- The ship’s safety officer suspended the hot work immediately and reported the near miss to the yard safety officer and master,
- A meeting was convened shortly after with all involved to discuss what went wrong and what could be improved. These were implemented immediately,
- A mass toolbox briefing was held the next day with all contractors attending the vessel to discuss the initial findings of the incident,
- Shipyard completed over 400,000 man hours during the refit without injury.
What went wrong (Critical Factors):
- The yard’s permit to work system allows hot work permits to be suspended, but not cancelled nor removed from site, during activation of hydraulic systems. This is typically coordinated at the daily work planning meeting and the permits are not returned to the yard HSE Officer,
- Communication from the meeting to the sub-contractor foremen and subsequently the workers was poor, resulting in lack of understanding. The venue of the daily work planning meeting was becoming congested and the contractor foreman was too far away from the discussion to clearly understand the instructions.
Lessons learned & Recommendations:
- Changes should be made to the Safety Management Plan for vessel refits, or to the HSE elements of the contractual documents between owner and shipyards where they exist, to ensure that actuation of hydraulics, or transfer of other flammable fluids, forms part of the yard’s permit to work system,
- Consideration should be given to the venue of daily work planning meetings, including but not limited to, general location, noise levels, seating arrangements, essential attendees, policy on disturbances, etc where these are able to be modified,
- It must be ensured that any key messages resulting form the daily work planning meeting are adequately passed to the yard workers and sub-contractors. The use of daily toolbox talks would seem to be the best method.
In conclusion the importance of adequate communication must be the significant root cause of this near miss – whether this is verbal or via posted information (including hot work permits). The challenge is to ensure that all those involved in the repair of vessels in a shipyard are fully aware of the work of others and the systems still in operation.
The efficiency of the permit to work system used by shipyards must also be vetted thoroughly, possibly as part of the HSE inspections already carried out to keep them on the approved list, and measures put in place to ensure that the recommendations are implemented.