MAIB: What Could Go Wrong?
The U.K. Marine Accident Investigation Branch (MAIB) has released its latest collection of cases detailing analyses of accidents involving vessels from the merchant, fishing and recreational sectors.
“It could be said that the chaos caused by a weather system described by the media as “the Beast from the East” was exacerbated by a collective failure to prepare for the worst,” says Steve Clinch, Chief Inspector of Marine Accidents, introducing the Safety Digest. “Regular readers of the MAIB’s Safety Digest will be aware that failure by seafarers to prepare for the worst, or at least properly consider the potential risks before commencing a voyage, operation or task has been an enduring theme. I made a very similar observation when writing my first introduction to the Safety Digest in 2010 and on several occasions after that!
“Almost eight years later, my final introduction provides the same message; most of the incidents described in the following pages could have been avoided had the protagonists taken the time, beforehand to simply ask themselves “what could go wrong?” and put in place appropriate control measures to prevent a bad outcome.”
Every accident provides a learning opportunity which often transcends traditional operational barriers, says Clinch.
Citing a Ro-Pax vehicle deck fatality described in the Digest, Grant Laversuch, Head of Safety Management and Designated Person Ashore at P&O Ferries, says: “the C word appears; complacency. It is an easy way to explain a multitude of errors away, but if we really understood what complacency was, it wouldn't exist.
“Complacency isn't unique to seafarers; it is a weakness of human beings. We are all vulnerable to complacency in our daily lives. There are many definitions of complacency, however for me it is when we feel comfortable with something and start to let our guard down.”
How do seafarers, guard against falling into this complacency trap? “For me it is about never fully feeling comfortable in anything we do,” says Laversuch. “The day we feel fully comfortable in anything we undertake, is the day that we are in for a nasty surprise.
“We are all human and we all make mistakes, seafarers and management alike. We all need to acknowledge this, recognize our mistakes, share and support each other, challenge ourselves and challenge others.”
Ro-Pax - Vehicle Deck Fatality
An experienced AB was acting as a banksman for the loading of an unaccompanied piece of freight that was being loaded by a tug-master. The crew member became trapped between the rear of the trailer and a vent housing. He was fatally injured.
The vessel completes a 24 hour rotation between two ports, six days a week. The deck crew were employed to load and lash vehicles. Five crew were involved in this operation on the upper vehicle deck and were loading two pieces of unaccompanied freight being reversed in by a shore tug-master.
Normally crew members guiding reversing freight into position stand in a position of safety while they are directing the tug driver. Once the trailer is in the correct position a whistle is then blown by the banksman to indicate that the tug should stop.
The tug driver reversed the trailer, jack-knifing to the left and right to achieve a straight trajectory and line the trailer up with the freight already parked. He was expecting to hear a whistle signal from the banksman when the trailer reached the correct position. Meanwhile, the crew member acting as the banksman had moved from a position of safety and was crushed between the rear of the trailer and a vent housing. The whistle signal instructing the tug driver to stop was not given.
Although derived from the company’s internal investigation, the following lessons are also relevant for the crews of many vessels engaged in ro-ro operations.
• A safe system of work is required to ensure no crew member moves into a dangerous zone behind moving freight.
• Whistle signals should only be used to stop a vehicle. Whistle means STOP.
• Crew members and tug drivers need to work as a team. Watch my Back – always look after your team mates.
• Training should involve both ship and shore teams working together.
• If the tug driver loses sight of the banksman he must stop.
• If the banksman loses sight of the tug driver he must blow his whistle.
The Safety Digest is available here.