CHIRP has received many reports which may be categorised individually as minor near misses. Whilst the reporting of these shows that a behavioural-based safety programme is in place, it also shows that the Deadly Dozen has yet to be embraced.
The Deadly Dozen – see MGN520
Several of these near miss “one liners” are detailed below. They all had remedial action applied, in the form of direct intervention.
- A first trip deck hand’s first mooring experience had him actively tending moorings. CAPABILITY. (The inexperienced deck hand should have been mentored until he was deemed experienced enough to actively engage in mooring operations).
- A bunker tank nearly overflowed when the engineer overseeing the operation left to answer an engine room alarm. DISTRACTIONS. (A dangerous oversight – proper planning would have freed up personnel in order to prevent this near miss).
- A lower forepeak space required cleaning – during the planning the supervisor asked for everything to be made ready in half an hour and he would return at that point. When he returned personnel were already at work inside the compartment even though they had not received an Entry Permit. COMMUNICATIONS. (The supervisor had in fact tested the compartment and had gone off to write up the permit – the crew however misunderstood the correct procedure).
- An oiler taking daily tank soundings walked under a crane that was in use for storing operations. SITUATIONAL AWARENESS and ALERTING. The oiler could not have been aware of his surroundings or else he would not have stepped under a crane with a load. But who had the forethought to stop him?
- Sunglasses were used instead of safety goggles during deck scaling maintenance CULTURE, COMPLACENCY and LOCAL PRACTICES. If “That’s the way we’ve always done it around here”, is the philosophy then the culture both on board and ashore needs to be modified to change how people think.
- A supervisor became involved in a mooring operation. The ship had undertaken several port calls in the previous few days, with associated cargo and administrative operations. Amongst other factors, FATIGUE could have been an issue. Tired people make mistakes and the supervisor should have restricted himself to supervision and NOT become involved in the actual work.
The above reports are encouraging and indicate that people are thinking about safety, but it is worth remembering that the Human Element can involve multiple factors. Take the first example of our deck hand getting involved with mooring – this points to a poor on-board safety culture, a lack of standard operational procedures, and a poor company culture within the Safety Management System. A proper risk assessment and toolbox talk would have prevented the deck hand from getting involved.
Some of the examples may sound very familiar from your own ship – if so, what are you doing to prevent it from happening in the first place? All of the above examples could have been prevented if the people on board, backed up by shore management, had a heathy TEAMWORK ethic which encourages people to challenge unsafe procedures where appropriate, and which involves proper planning and co-ordination of onboard activities. Good planning also reduces the danger of people being placed under too much PRESSURE since tasks are more evenly distributed.
For any “near misses” that you become aware of, try to decide which of the twelve aspects of the Deadly Dozen are most appropriate. There may be more than one, in fact there are often several categories. From a personal perspective, thinking about your surroundings or the tasks that you have been allocated helps you become more self-aware and able to see the dangers before they cause an accident. Why not discuss the near misses that you experience at your Safety Committee meetings and bring in the aspects of the Human Element? You might be surprised at the results.