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Having Trouble Explaining the Difference Between Near Misses and Unsafe Acts?

Is it a near miss?  Or was it an unsafe act?  Maybe just an unsafe condition.  What’s the difference and how do you explain it to your crew when introducing them to your safety management system?

Check out for more cartoons like the one below.  It’s a good visual explanation of the differences between some of the terms used in our safety management systems.  As the safety culture of a vessel and/or company evolves, many are moving away from the simple reporting of near misses.  By identifying (and resolving!) unsafe acts and unsafe conditions, the goal is to break the error chain before a near miss even occurs.

So, where is YOUR safety culture on the evolution chain?


Near Miss - Lifting Gear

Cargo Moment : Twin 20′ Lift Gone Bad

20 twin-pick

The introduction of the standardized cargo freight container changed the shipping industry forever.  From literally weeks to discharge and load a ship, cargo operations are now measured in hours.  Moving tens of tons of cargo at a time is not without its hazards and drawbacks, however.

One of those drawbacks is when a container lift goes badly.  Whether it is equipment failure or operator error, even the highly mechanized operations of loading and discharging containers can sometimes slow to a crawl or stop entirely awaiting the resolution of a problem.

Spreaders fail.  Wires Fail.  Load plans change.  Human error rears it’s ugly head.  Any of these or numerous other factors can make your day go bad very quickly.  What happens next is often up to the ingenuity and resourcefulness of those involved.  For those who have had containers hanging off spreaders, hatch covers fall in the hold or containers jammed in cell guides, you have an idea of what steps to take.  For those who have never been in those situations, it may be time to play, “What if….?” with yourself and have a rough plan in mind.

The TT club looks at the specific problem of 20′ twin-lifts in their latest TT Talk.  Take a look and think about the factors involved.  Remember these safety ideas when working with containers :

1. Do not walk under a suspended load.  Ever.  That hard hat might save your life if a twistlock falls off a container, but will not save you if the container falls off the spreader.

2. On your ship, you are the expert.  Yes, longshoremen conduct cargo operations every day, but they may not know the idiosyncracies of your vessel or may not be as concerned about damage to the vessel.  If you have doubts, stop cargo operations until the situation can be clarified or resolved.

3. If any near misses occurred during cargo operations, make sure they are documented.  By passing along the information, others may avoid the same situation.

Lets be safe out there.

Additional Reading and Links

TT Talk – Costly Pickings : the persistent accidental twin-lift problem

Shipping and Freight Resource : Is the current inspection regime for containers good enough..?

Cover photo courtesy of Felixstowe Dockers

Risk Moment : Shipyards and the Perfect Storm of Risk

Shipyards are a time for getting the maintenance done – and frequently, it is maintenance that can’t be done under normal operating conditions or that which requires specialized skills/equipment.  This month, The Swedish Club looks at a shipyard evolution in their Monthly Safety Scenario.  While fictitious and designed to get shipboard operators thinking, this scenario, like their others, is entirely plausible.

Working at a height or lifting large objects are common procedures onboard almost any vessel.  Seafarers are used to the evolution and familiar with the procedures and equipment used.  Whether it is maintenance on cargo gear, work in a cargo hold or simply changing a lightbulb at a masthead, many jobs at height have been done before and all are satisfied that the risks have been identified and mitigated.  Likewise, with lifting operations, there are many lifts such as hatch covers, grabs and deck machinery that weight tens of tons and are done safely over and over.  Again, the risks involved have been identified and controls put in place to mitigate them.

The perfect storm of risk sometimes gathers during shipyard periods.  Relatively common procedures – working at a height and critical lifts – are combined in an unusual circumstance and quite possibly under time pressure.  Looking at The Swedish Club’s Injury – While Climbing, it can be seen that this perfect storm is made complete with the assistance of an eager, yet inexperienced cadet.  Like so many incidents in the maritime world, the root causes, preventive measures and corrective actions in this scenario are numerous.  Ranging from a comprehensive risk assessment to a toolbox talk to assembling the job team, the methods of preventing the injury and losses detailed come from many directions.

Read through this scenario, answer the questions at the end and play, “What if….?” with yourself.  Because, at the next yard period, this might not be just a hypothetical situation for you.

Let’s be safe out there.

Additional Reading and Links

The Swedish Club – Monthly Safety Scenario – December 2014 – “Injury – While Climbing”

The Gard – The Dangers of Working at Heights Below Decks

ILO – Accident Prevention Onboard Ship and In Port

Going Down the Rabbit-hole of Enclosed Space Entry

Confined Space Photo

Steel surrounded me on all sides with barely a half-meter clearance in any direction, concentrating the hot, humid Indian Ocean air that had been forced in over the previous day. Twenty-five minutes and I was only halfway across the after peak water ballast tank that was twenty meters wide. As the sweat rolled down my back, I thought about the International Maritime Organization’s (IMO) and P&I Clubs’ increased emphasis on enclosed space safety. Perhaps they had a point; because, if I had a problem, it would be a long time before anyone got to me.

 Much like Alice chasing the rabbit down its hole and winding up in Wonderland, once we dive into enclosed space entry, there’s a whole ’nother world. From regulations, drills and training to rescue equipment, risk analysis and atmosphere testing, there is enough information and skills on which to base an entire career. Unfortunately, as mariners, it’s only part of the job. A job that must be done safely, as the consequences can be dire.

 Between 1998 and 2009, nearly 200 {enclosed space} casualties, including 96 fatalities – the majority of which were attributable to procedures not being followed!

 According to Steve Clinch of the United Kingdom’s Marine Accident Investigation Branch (MAIB), this may be the tip of the iceberg. Since 2009, there have been a further 12 enclosed space accidents resulting in 10 fatalities and 7 injuries – in the MAIB database alone. Worldwide, the number of reported and unreported incidents is expected to be far greater.

 Virtually all the casualties of enclosed space accidents are the result of atmosphere deficiencies. Whether due to a lack of oxygen or toxicity due to carbon monoxide, hydrocarbons, hydrogen sulfide or other substance, it is apparent the correct precautions are not being taken. Many enclosed space incidents continue to have multiple casualties due to rescuers not exercising due care before attempting the rescue.

SOLAS regulation III/19 (amended) : …on emergency training and drills, to mandate enclosed-space entry and rescue drills, which will require crew members with enclosed-space entry or rescue responsibilities to participate in an enclosed-space entry and rescue drill at least once every two months.  – Adopted by IMO’s Maritime Safety Committee in June 2013

 Fortunately, there are a lot of stakeholders in the enclosed space entry arena, ranging from the lofty IMO to flag states to insurance companies to shipping companies and all the way down to the deck plates on the ship. While their stakes differ greatly, from the very personal life and limb of the seaman to the more nebulous reputation of a shipping company or flag state, the goal is the same – no incidents.

 IMO’s Secretary General Koji Sekimizu has initiated an “Accident Zero” campaign with the initial goal of reducing all maritime casualties by half by 2015. Directly addressing enclosed space entry was IMO Resolution A.1050(27) Revised Recommendations for Entering Enclosed Spaces Aboard Ships, adopted in November 2011. On its own, this resolution provides a robust base for an enclosed space safety program.

 Some of the other stakeholders aren’t so surprising, with shipping companies providing their crews guidance through their safety management systems (SMS). Other stakeholders are a little more surprising, with insurance companies or protection and indemnity (P&I) clubs providing excellent guidance on enclosed space safety (and a multitude of other subjects) through their Loss Prevention programs. One such resource is The Standard Club’s A Master’s Guide To : Enclosed Space Entry.

 Squeezing my body through the web frame openings to get to this spot had required careful coordination of all limbs, hardhat and the gas meter slung over my shoulder. Not infrequently when performing these contortions, my exhaled breath triggered the low oxygen alarm on my multi-gas meter. The momentary rush of adrenaline when this happens is, I’m sure, only a taste of how a real emergency would feel.

 An informal poll of senior merchant mariners recently revealed a lack of formal training in either Enclosed/Confined Space Entry and Rescue or Gas Free Engineering. While most companies provide training on their permit-to-work program or the use of gas meters, more specialized training is lacking.

 Gas free engineering is a term more normally associated with the military. While certainly not training people to the level of a marine chemist, it does promote a feeling of confidence in equipment and procedures. Unfortunately, while some in the maritime industry do have this training, it is only those with specific military backgrounds.

 Enclosed (or confined) space entry training is not uncommon, but as yet is not mandated. With the amendment to SOLAS III/19 requiring bi-monthly rescue drills, perhaps mandatory training is down the road? Until then, it is less likely that it will be taken voluntarily.

 Additional training in these areas will certainly improve the abilities of seafarers in enclosed space entry. However, it is not only the knowledge of the matter, but the ability to consistently and properly apply that knowledge that will reduce the casualties associated with enclosed space entry.

Additional Reading and Links

MAIB, Steve Clinch, Chief Inspector of Marine Accidents, Entry Into Enclosed Spaces – An Overview.

International Maritime Organization (IMO), Resolution A.1050(27) Revised Recommendations for Entering Enclosed Spaces Aboard Ships

 The Standard Club,  A Master’s Guide To : Enclosed Space Entry.