When it comes to accidents involving injuries or fatalities during onboard operations, you can almost always boil the root cause down to one of three things:
• The work being performed was not properly planned,
• The plan for the work was not followed,
• Or the scope of the work changed.
First let’s address failure to adequately plan the task:
Before the start of any job on board a vessel, it is essential that the scope of work is understood by everyone directly and indirectly involved. In addition to understanding the various steps of the job, crewmembers must be trained in recognizing and controlling the injury hazards associated with performing these steps.
Most shipping and offshore companies have a variety of tools to aid workers in effectively planning tasks and identifying hazards, but often the proper use of these tools is not fully understood. In other instances, the use of these tools becomes so repetitive that complacency sets in.
Below is a quick review of some of the most common tools and how they can be better used to prevent incidents from happening.
Work permits: The concept of work permits is nothing new, and almost everyone working aboard a vessel has had experience using them. The challenge is ensuring the work permit is being used in the spirit in which it was intended. Simply filling out a piece of paper does not prevent someone from getting hurt. In order for a work permit to be effective, the supervisor responsible for authorizing the work must (at a minimum) consider the following:
• The qualifications and experience of the person(s) doing the job,
• The isolations of potential energy sources,
• The effect the job may have on other critical systems,
• The effect the job may have on people working nearby,
• The level of pre-job planning,
• The tools and personal protective equipment (PPE) needed,
• The location of the work site (confined space, extreme heat, etc.),
• Present and forecasted weather,
• Upcoming operations that may affect or could be affected by the task.
Failure to appropriately consider any of these factors can set the stage for an injury or incident to occur and this responsibility must never be taken for granted by the captain, chief engineer, or other person in charge.
Energy isolation permits: In addition to a work permit, most company safety management systems require a separate energy isolation permit or “isolation certificate” to perform tasks that involve contact or exposure to potential energy sources (electrical, mechanical, pressure, gravity, temperature, etc.). This is why it is so important for the person authorizing the work permit to understand the level of planning that went into the task. If there are any questions, the authorizing person needs to visit the worksite with those performing the task and review any potentially unidentified energy sources.
When a potential energy source has been identified, at least one of the following three control measures must be utilized:
• Safely remove or release the energy source,
• Prevent the energy sources from releasing,
• Put controls in place to safely handle any unwanted release of energy.
Job safety analysis: Whether you call it a job safety analysis (JSA), job hazard analysis (JHA), activity hazard analysis (AHA) or a risk assessment (RA), chances are your company already has some sort of documentation program that provides crew instructions on how to perform certain tasks safely.
Unfortunately, there are many cases where these documents are incomplete, incorrect or not applicable for the equipment or systems currently in use on the vessel. In order to ensure the effectiveness of your company’s written job safety procedures (JSAs), supervisors and crew need to periodically review them giving consideration to the following:
• Correctness: Over a certain period of time, a crew will naturally find the safest and most efficient way to perform a task. The challenge is ensuring written procedures are updated to capture these new techniques so future and relieving crews can benefit from them as well.
• Applicability: Perhaps the JSA is written for a task that now involves new equipment not previously addressed. For instance, you may have a JSA for operating an oily water separator that was actually replaced last year by a new unit.
• Clarity: Sometimes JSAs are not very explicit. Try to be as specific as possible when defining responsibilities. Instead of saying “inspect explosion proof-light for damage,” a more effective JSA may say “ensure cable on explosion-proof light is free of exposed wires, properly terminated and lamp lens is free of any cracks.”
Checklists/prompt cards: Another potentially effective tool to assist crewmembers in the safe planning of their work is the use of checklists or prompt cards. These cards are typically the size of a business or index card and have various hazard identification prompts on them, such as potential sources of energy, hand safety considerations or a list of PPE requirements. Shipping companies, drilling contractors, and oil majors all have some variation of these tools.
These tools lose their effectiveness when a company goes overboard and rolls out a new card every year. One gentleman I know has kept every checklist and prompt card tool ever given to him over the course of his career. All told he carries over 15 different cards his company has encouraged him to use to identify potential hazards in his day-to-day job duties.
Going overboard with the procedural “safety tools” used on board a ship will only discourage the crew and dilute the entire risk assessment process. Stick to one or two of the most important “safety tools” or consider consolidating the ones currently in place. Chances are there is repeat information on some (if not all) of the safety, health and environmental “memory joggers” your company uses. The more QHSE (Quality, Health, Safety & Environment) tools your company uses, the less effective each individual tool becomes.
When the task changes
There are few operations performed by professional mariners that are ever successfully completed without some sort of change being introduced (different tool, new people, weather change, etc.). You can have the best pre-planning “tool box” meeting in the world and it may never fully account for every possible curve ball that may be thrown at your crew.
The challenge is recognizing the change and ensuring that you put controls in place to properly manage it. “Management of change,” one of the most significant buzz phrases circulating in the industrial safety profession over the last decade is based on this principle. In order to successfully manage change as tasks are being performed, there are many things a supervisor can do. Here are a few of the most import ones:
• Supervision: During the task, it is important for the supervisor to periodically check up on the progress and ask the team how things are going. This is effective for several reasons. First, it enables the supervisor to ensure the plan is still being followed. Second, it allows the supervisor to see if there are any additional hazards present that weren’t considered during the initial planning of the task. And third, it demonstrates that the supervisor cares and does not see the work-permit or job-safety-planning requirement as a paper exercise.
• Safety breaks/timeouts: Another effective technique for assessing changes needed to the plan (or any additional risks) is to take breaks at planned intervals to step back and review the work. Revisit the plan and ask yourself what’s coming next and what additional tools or people may be needed to complete the next step safely.
• Safety observers: For complex jobs on board a vessel, it may be a good idea to assign a dedicated “safety observer” to monitor the task as it is being performed. Like a fire watch or standby watchman, this dedicated safety observer can step back and monitor the operation throughout its duration (or take turns with other crewmembers involved in the task).
The idea is to have at least one person watching the job who isn’t directly involved and who can recognize change and shut down the operation if it appears the job is starting to deviate from the original plan.
Failure to follow the plan
Perhaps the most challenging element to control when it comes to preventing injuries and incidents is making sure the crew actually follows the plan — in other words, the people performing the job do what they say they are going to do (the “human element”). A momentary lapse in judgment or minor deviation from the original plan can trigger a serious medical emergency in an instant.
The only real fix to this that I’ve found is explaining to the crew exactly why following the plan and staying focused is so important. It is not a matter of complying with the International Safety Management Code, it is not a matter of following flag and coastal authority requirements, and it is not a matter of following company policy. It is about making sure that people don’t get hurt.
People who sail on ships and work offshore typically do so to afford a better life for their families. However, no amount of money will ever replace the irreversible consequences of being severely injured or killed because of a crewmember’s deviation from an agreed upon plan.
No system is perfect
Safety management systems will never be perfect. There will always be the wild card of a crewmember’s willingness to participate in the process. For a maritime company to operate incident free, it takes a personal commitment and focus from everyone involved, from shipping company executives on down to the hands scrubbing the decks. Even if a company were able to operate incident free over a certain time period, just as with a mutual fund, past performance is no guarantee of future results.
When we adequately plan our business, execute the plan and manage the changes that may come along the way, we’ll have our best chance yet of preventing injuries aboard ships.
Ben Dinsmore is a licensed master (oceans, any gross tons) and offshore installation manager (unrestricted). He is the captain of an oil exploration and research vessel (drill ship) and enjoys speaking about maritime safety and operational efficiency. He can be reached at firstname.lastname@example.org.