Incorrect valve alignment

Outline:

A fresh pair of eyes identified an incident waiting to happen on a chemical / oil product tanker.

What the reporter told us:

The vessel had orders for several loading ports, and in each port different parcels of cargo were to be loaded. The cargo loading plan was made out and sent to various parties for approval (including the office ashore) and agreed by everyone. The vessel’s design gives two options to collect oil / cargo in the event of a spill on deck.

  • In the port slop tank (aft)
  • In bulk (1m³) spill drums (stb’d side midships)

Before arrival at the first loading port, spill collection was lined up to the port slop tank. In the first loading port the ship loaded a parcel of fish oil into a group of tanks, including the port slop tank.

On arrival at the second port, to load a parcel of ethanol, the spill collection arrangements were left lined-up to collect any cargo spillage into the port slop tank. A delayed crew change also took place at the second loading port.

After the crew change, during handover, the new Captain noted this arrangement and immediately had it changed to collect any cargo spillage into the spill drums.

Further dialogue:

CHIRP engaged with the reporter and whilst there was no further information to add to the initial report, the reporter considered that the extended trips being worked by the crew (8-9 months) during the COVID-19 pandemic was a contributary factor in this human error.

CHIRP comment:

This is a simple report about a human factors incident where a mistake was made. The question is why did those people make a mistake?

99% of the time, the people involved would not have made such a basic mistake, but on the rare occasion when a mistake is made (because mistakes do happen) the normal checks and balances that are incorporated into this routine operation would have identified and rectified it. However, on this occasion those checks and balances failed to identify the mistake and so the holes in the hypothetical swiss cheese aligned and waited for the final hole (a spillage of cargo) to line up, which would allow the near miss to by-pass the incident stage and turn into an accident.

Was fatigue and distraction caused, or exacerbated, by the extended tours of duty due to COVID-19? Potentially this was a contributary factor leading to this human error. Procedures, instructions and operational checklists with regards to using the slop tank to carry cargo should be reviewed, because this mistake slipped through the net too easily.

 

 

Report Ends………………………….

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