1

Objectives of the Program

2
Lesson Learnt
The experience itself is the
best way to learn.
How many times do we have to
repeat the same mistake to
recognize it as a mistake and to
learn a lesson
Lesson Learnt Circulars
Injury During Dismantling of Piston
Crown – 10 Jan 2020

Burn injury due to hot water scalding

– 17 Jan 2020.

Serious injury during greasing of mooring

winch – 18 February 2020
Lesson Learnt Circulars
Right hand middle finger injury
– 20 May 2020

Finger cut Injury by Hatch Cover of E/R – 30

April 2020

Increasing Arm Injury Case on Fleet Vessel

10 Feb 2020
Lately, more and more people have unconsciously invaded the "dangerous
condition" Recheck that you are avoiding dangerous conditions in all
situations.
 Lesson Learnt Circulars

What could be the

root cause?

Preventive
actions?
 Lesson Learnt Circulars
Burn injury due to hot water scalding –
1st Jan 2020.
 Lesson Learnt Circulars
Burn injury due to hot water scalding – Jan 2020.
What contributed to this Accident?
 Lesson Learnt Circulars
Serious injury during greasing of mooring winch
– 18 February 2020
 Lesson Learnt Circulars
Serious injury during greasing of mooring winch –
18 February 2020
 Lesson Learnt Circulars

Right hand middle

finger injury
– 20 May 2020
 Lesson Learnt Circulars

Finger cut Injury

by Hatch Cover of
E/R – 30 April
2020
 Lesson Learnt Circulars

Finger cut Injury

by Hatch Cover of
E/R – 30 April
2020
 Lesson Learnt Circulars
Finger Crushed Between
Anchor Chain Link and Stopper
13 Oct. 2021

Bosun finger caught

in between anchor
chain link and stopper
(re-enactment)
 Lesson Learnt Circulars
Finger Crushed Between
Anchor Chain Link and Stopper

Bosun Crushed
Index Finger
Fall Injury
Lesson Learnt….
Arm Injury Case
Trap Injury
Trap Injury
Preventive
actions?
Crew Injury during tank cleaning operation
Lesson Learnt with Hoses
SAFETY ALERT 001/2021
05 Jan 2021
Left Arm Injury due to Slipped Down
Three Point Contact principle in ladders:

When climbing up to a higher level or

down to a lower level, always maintain
three points of contact— either two
hands and a foot or two feet and a
hand.

When three points of contact are

maintained, the individual's center of
gravity is controlled and they are a lot less
likely to lose their balance.
Lesson Learnt and Action Required by All Vessels

1. Routine tasks should not be neglected in JSA and

should be discussed to analyze the hazards involved.
Where applicable a detailed RA should be conducted.
2. Inadequate illumination, rain and weather should be
discussed during JSA as a hazard and appropriate
measures ensured. (in case of Slip).
3. Training of crew regarding safe working practice and
situational awareness. While preparing JSA, senior
officers shall brief the crew and record
tools/equipment to be used for the job in JSA.
Lesson Learnt and Action Required by All Vessels

4. All ladders on deck should be anti-skid (Case of Slip)

5. It is vital to maintain Situational awareness especially
while working with corrosive chemicals. (Eye injury)
6. Extreme caution advised while exercising on deck
and in gymnasium. Consider potential risks while
exercising for avoiding resulting in injuries.
7. These incidents should be discussed in the SHEC
meeting to prevent the recurrence of similar
incidents onboard.
Lesson Learnt….

32
Job Safety Analysis
JSA
Identify specific dangers
related to specific tasks in
the workplace.
Risk Assessment
RA
A systematic process of
evaluating a potential risk
that may be involved in a
projected activity or
undertaking.
33
Lesson Learnt….

34
 Collision with outbound Vessel
near approach Channel
MT ESTEEM HOUSTON while approaching buoyed
channel towards Breakwater at Callao, Peru collided with
the outbound vessel OCEAN PHOENIX TREE in location
12-02.52 S / 077-11.23 W. The incident occurred on 11
Dec 2021 at 1835 LT with Pilot on board. Other vessel was
bulk carrier exiting breakwater. Vessel sustained damages
at the port side quarter hull area iwo frame 23, between
longitudinal 38 and 39 with in E/Room.
No pollution due to the collision. No crew injury due to the
incident.
ECDIS and RADAR Screenshots

36
 Collision with outbound Vessel
near approach Channel

The consequences
Hull rupture iwo Frame 23 between longitudinals 38 and 39.
As per preliminary inspection it was found the Shell plate with a
rupture behind the ECR on 2nd Deck, the opening is appx. 70cm
long & Height 130 cm In way of Longitudinal 38 & 39 - Frame 23.
Delays in discharging of Cargo destined for this Port.
 Collision with outbound Vessel
near approach Channel
Causal factors, Immediate Causes, Direct Causes:
Immediate cause is attributed to communication between the
two Pilots and agreeing to pass Red to Red but outbound Vessel
Pilot disembarked with in the buoyed channel before the critical
maneuver was completed. Also Pilot on outbound vessel failed
to ensure that outbound vessel Master understood and will
follow the correct maneuver as agreed with Pilot of own Vessel.
Lack of proper watchkeeping and situational awareness of
outbound vessel and her failure to respond to all VHF warning
Calls and sound signals by own vessel and port control.
Possible miscommunication between Chinese Master and local
Pilot of outbound Vessel while communicating in English.
 Collision with outbound Vessel
near approach Channel
Preventive/Corrective Actions:
Master to ensure to discuss with Pilot movement of any vessels
in and out of the Port when own vessel is likely to proceed.
As far as possible, Master to agree with Pilot to wait for any
outbound vessel to clear the channel before proceeding
inbound.
Master to ensure to check with the Pilot on intentions of
outbound vessel and agree on the maneuver before proceeding.
In case of any doubt, maneuver to be aborted till outbound
vessel is past and clear.
Lesson Learnt….

40
 Incident 1
Loss of Port anchor and cable
Situation:
 Type of Vessel: Bulk Carrier (DWT: 80,000)
 Draft: Forward 4.74m, Aft 7.25m
 Charted depth: About 53 meters
 Weather: Gentle breeze, daytime.
 Wind: Easterly – 8 to 9 knots.
 Current: ESE about 1.5 knots, high tide
 Visibility: Good visibility
 Vessel under pilotage.
 Tanjong Bara anchorage, Indonesia.
THE CONSEQUENCES

 Port Anchor and the entire anchor chain was lost.

 Port side bitter end, quick release arrangement and
the chain locker itself was damaged.
 Vessel was off hired, leading to loss of reputation
and commercial losses.
 Vessel had to be off hired and taken to repair berth
for chain locker repairs and for installation of new
anchor and chain leading to additional costs of
about USD 140,000.
THE CONSEQUENCES

Damage to bitter end and chain locker ( bulkhead caved in).

What went wrong/ the root causes
 Non compliance with company’s anchoring procedures.
 No pre-anchoring meeting with the anchoring team to
discuss anchoring plan. Hence, the Officer in charge of
anchoring team was not familiar with the depth, anchor cable
final length etc.
 Master was aware of the company anchoring procedures but
disregarded the same and chose to follow pilot’s advice to let
go anchor instead of walking back all the way through.
 Forward station followed orders from the bridge for walking
back up to 2 shackles in water and then to disengage the gear
to make anchor ready for letting go.
 Bridge ordered forward to let go port anchor to 8 shackles in
water. Depth was about 53 meters at this moment, the
anchor was let go by forward and brake kept open finally
leading to complete loss of anchor and the cable.
Lessons learnt
 Follow company procedures.
 Conduct a meaningful Master – pilot exchange and
a pre arrival BTM.
 Do not over-rely on the pilot.
 Intervene/override the pilot if pilot’s actions are
contravening company procedures or are unsafe.
 Bridge team consists of OOW and helmsman who
are valuable members and shall be included in the
Master pilot exchange, BTMs and encouraged to
voice their doubts.
 Incident 2
Damage to Port Windlass
Situation:
 Type of Vessel: Cape Size Bulk Carrier (DWT: 181,319 MT)
 Draft: 18.30m even keel
 Weather: Fair weather, noon time.
 Wind: BF 5 / N’ly
 Current: SSW x 2.5 ~ 3.0 knots
 Visibility: Good visibility, day time.
 Depth: 30 metres to 36 metres. Seabed – soft mud.
 Vessel anchored at Taizhoumen anchorage no.1 –
Zhoushan, China.
 Port anchor 10 shackles in water.
CONSEQUENCES

1) Damages to port windlass and its components

rendering the winch and windlass non-operational.
2)Vessel had two discharge ports. Due to the damaged
windlass, there were delays in vessel berthing in both
ports.
• 1st disport: berthing delay of 5 days.
• 2nd disport: delay in berthing - 19 days.

Total off hire– 24 days.

3) Estimated cost for temporary repairs – USD 650,000.0
 DAMAGE TO WINDLASS

Damage to Hydraulic motor Damage to the gear teeth

Stuck chain link between gypsy Damage to the Main shaft support
wheel and shaft cover stud
What went wrong/ the root causes
 Excessive stress on the cable causing physical
damage to the hydraulic motor
 Gear was engaged before easing off weight on cable
 Cable was heaved up even when there was weight
and even when the windlass operator reported that
there was difficulty in heaving up anchor.
 Vessel pivoted with high momentum (Yellow circle)
around the cable with gear engaged causing severe
stress on windlass motor.
Lessons learnt
Anchoring team forward:
 Forward station should report cable direction, weight and
advise bridge to ease weight on the cable before engaging
gear.
 Forward station should engage gear only when the weight
on anchor cable is eased off and is up and down.
 Officer in charge of anchor station shall not ignore windlass
operator’s feedback
 Bridge should be informed immediately regarding the
heavy load on windlass.
 Officer in charge should cross checked engine and helm
movements with bridge.
Lessons learnt
On Bridge:
 Conduct BTM to discuss anchor heaving procedure, familiarize
with contents of BDP and sections containing anchoring, anchor
watch and heaving up anchor with anchoring team and bridge
team before anchoring operation.
 Bridge should verify and confirm cable direction, weight and ease
off weight on cable using engine before ordering forward to
engage gear.
 Bridge should order forward station to engage gear only once
anchor cable is up and down.
 Bridge shall keep forward station closely updated with engine
and helm movements.
 If after giving engine movement and helm for a prolonged
period, forward station does not report change in cable direction
or weight, always suspect and cross check.
 Incident 3
Intentional Release of Anchor
Scenario / Vessel
Description Opponent
Own Vessel – Anchored @ Pajaritos Vessel
“C” Anchorage.
 Drops Anchor at 9th Jan / 1018LT
 Draft: 6.6m / 8.6m
 Port Anchor 7 Shackles on Deck
 Depth – 34m // UKC – 25m
 Wind: NE x BF3
 Sea: Low
 Current: SE x 1.0 Kts
 Distance from Other vsl: 2.3 nm Own
Vessel
Other Vessel
 Chemical Tanker
 Draft: 8.4 m
Damages due to backlash from the
anchor chain

 Bow stopper slightly

bent at the hinge pin
joint & stopper pin
dislodged from
location.
 Indentation on the
beam bar of the
chain roller guide
 Minor indentation
on the Chain roller
guide.
What went wrong/ the root causes
 Inability of the opponent vessel to heave up anchor in time while
she was dragging and stay clear from own vessel.
 Lack of situational awareness/risk perception/risk awareness:
 Own vessel remained at Anchor on the onset of heavy
weather.
 Lack of proper monitoring of vessel’s anchored in the vicinity
especially during heavy weather & delay in detection of the
dragging vessel
 Lack of understanding that strong winds / inclement weather
not only poses a risk of anchor dragging but also makes it
difficult to heave up the anchor due to excess load on the
chain & windlass design limitation.
What went wrong/ the root causes

 Deviation from Company Policy / Procedure / Practice

 Non-compliance with BDP-03-07 Anchoring procedures
(Section 3.31.4 Rough Weather)
 Improper use of BDP-03-31D Critical wind velocity calculation
due to scanty weather information.
Lessons learnt
 Vessel’s to strictly comply with BDP-03-07 Section
3.31.4. Master to pick up anchor and proceed to safe
drifting location well in advance, in case weather is
expected to breach the Critical wind velocity
calculated as per BDP-03-31D.
 Diligent Anchor watches to be maintained at all time,
to have an early indication of any nearby vessel
dragging anchor & to have sufficient time to heave up
anchor.
Lesson Learnt….

57
Root Cause Analysis
RCA
Above the surface
you see the
SYMPTOMS
of the problem

Dig deeper to find the

Root Cause
of the problem
 5 WHYS

Step 1 – State the problem

Step 2 – Why it occur?
Step 3 – Why it happened?
Step 4 – Do this is succession until
you’ve asked WHY 5 times.
 Most common type of negligence
that leads to accidents and injuries:
• Improper Training
• Failing to Detect and Repair the equipment
• Failing to ensure Good Housekeeping
• Failing to assess the RISK and conduct proper
JSA – Job Safety Analysis
• Overworked, not having a much needed
breaks and rest.
 Make effective use of
“STOP AND THINK MORE”
To prevent injuries…!
http://www.maritimewellbeing.com/
 Online Feedback
 Your valuable feedback is most important to improve the
knowledge-sharing.
 This is completely anonymous, and you need NOT give your
personal information.
 Without this feedback, your
attendance/certification
cannot be completed.