Professional Documents
Culture Documents
Threats, Incidents, Controls and Consequences
Threats, Incidents, Controls and Consequences
Threats, Incidents, Controls and Consequences
Threats, incidents, controls and consequences. 2011 calendar with humorous illustrations based on the UK Clubs new risk assessment initiative.
HAZARD
Controls INCIDENT
Controls
WHAT IS RISK?
MON
TUE
WED
THU
FRI
SUN
SNAP-BACK ZONES Highlighting snap-back zones ensures that crew can easily see danger areas without having to purposely think about them while working
EMERGENCY EXITS All exits should be visible and clearly signed Doors should be functioning correctly and tested through regular maintenance
31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Paint hazard areas
Holiday!
JANUARY 2011
THE TIGER IN THE CAGE
DECEMBER 2010
6 7 13 14 20 21 27 28
1 2 3 4 5 8 9 10 11 12 15 16 17 18 19 22 23 24 25 26 29 30 31
FEBRUARY
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Although sixty per cent of UK Club claims are caused by human error, human error is often only the straw that breaks the camels back the last event in a chain of causal events. These causal events can normally be traced back to failures in one or more areas of ship operation, we sometimes refer to them as accidents waiting to happen. How can we reduce the frequency of these accidents waiting to happen. What controls should we be looking at to ensure the threat is contained and an incident does not occur?
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
ZOO: KEEPER LEAVES KEEPER LEAVES THE THEGATE OPEN GATE OPEN
Gate operates automatically Gate operates Zoo: Tiger Escapes TIGER
Dart gun used by Zoo Keeper Dart Gun used by zookeeper Dart gun used by zookeeper
TOOLBOX TALKS
Toolbox talks and work planning meetings These are pre-work meetings held on board They should include, as far as practical to do so, the following:
MON
TUE
WED
THU
FRI
SAT
SUN
Risk assessment of operation to include the plan to be discussed and evaluated with the team members Safety matters, to include: - Discuss the job plan overall - What is the job, and procedure to follow - Who will do what - Discuss the safety rules for the area of work to be done
What could go wrong What are the main hazards Assess the risks and how do you eliminate them Get all to participate to create ownership of safety in the job to be done and full safety awareness Ensure as far as possible all personnel understand the safety rules for the job to be done Remind all of the STOP procedure if the job changes (i.e. weather hazards, additional ropes required, winch problems, minor and major accidents should occur)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
JANUARY
FEBRUARY 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
MARCH
7 14 21 28
1 2 3 4 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23 24 25 26 27 29 30 31
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
Permit to work including Gate operates automatically checklist completion prior to job commencement
Dart gun used by Zoo Keeper Dart Gun used by zookeeper Emergency equipment adequacy/availability
MOORING OPERATIONS
MON
TUE
WED
THU
FRI
SAT
SUN
MOORING Using a split mooring winch correctly is essential. The top photo shows the correct use, with the warp in good condition. In the bottom phot, the warp has been left on the drum end and the mooring warps are spliced, seriously reducing their strength
7 14 21 28
1 2 3 4 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23 24 25 26 27 29 30 31
FEBRUARY
MARCH 2011
Rope badly stored on wet deck GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
MOORING & KEEPER LEAVES THE UNMOORING GATE OPEN OPERATIONS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
MOORINGS UNDER TENSION/ Caged Tiger ROTATING MACHINERY
APRIL
4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28
1 2 3 8 9 10 15 16 17 22 23 24 29 30
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
Trade has failure alarm competancy of Gate personnel to perform required duties
Dart gun used by Zoo Keeper Dart Gun used crew to deal Capability of by zookeeper with incident
MON
TUE
WED
THU
SAT
SUN
HATCH COAMINGS In the good example above, the compression bar and drain channel are in good condition and the coaming is free of rust and other debris. Badly corroded compression bars and drainage channels are likely to damage latch lid rubbers and allow water to pass into the hold
4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28
APRIL 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
KEEPER DAMAGE WET LEAVES THE GATE OPEN Gate operates automatically
1 2 3 8 9 10 15 16 17 22 23 24 29 30
MAY
MARCH
Hatch rubbers should be undamaged and clean, well packed and soft, so that they offer good compression and seal. Where rubbers are old, hard and cracked they can allow water ingression
7 14 21 28
1 2 3 4 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23 24 25 26 27 29 30 31
30 2 9 16 23
31 1 3 4 5 6 7 8 10 11 12 13 14 15 17 18 19 20 21 22 24 25 26 27 28 29
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
Weather routing
Regular has failure alarm hose test/chalk Gate test or ultra sonic test on hatch covers
Dart gun used by Zoo Keeper Dart Gun used by zookeeper Learning from incidents
COLLISION AVOIDANCE
MON
TUE
WED
THU
FRI
SUN
May Day ?
BRIDGE DISTRACTIONS Distractions are often the cause of groundings or collisions and are often caused by other duties or paperwork that need to be carried out by watchkeeping officers. Sometimes the distractions are of a more personal nature such as mobile phones and music systems. Bridge computers, used for performing routine duties, should not be used for entertainment or amusement PROPER PROCEDURES In some collisions or near misses, watchkeeping officers have shown a lack of knowledge of what to do in such emergancy situations. Familiarity with regulations and publications such as Rules of the Road is essential
30 2 9 16 23
MAY 2011
31 1 3 4 5 6 7 8 10 11 12 13 14 15 17 18 19 20 21 22 24 25 26 27 28 29
APRIL
4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28
1 2 3 8 9 10 15 16 17 22 23 24 29 30
JUNE
6 7 13 14 20 21 27 28
1 2 3 4 5 8 9 10 11 12 15 16 17 18 19 22 23 24 25 26 29 30
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
REDUCED KEEPER LEAVES THE GATE OPEN VISIBILITY Proper lookout Gate operates automatically maintained at all times by all available means
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
Dart gun used by Zoo Keeper Dart Gun used by party Use of third zookeeper assistance
POLLUTION - BUNKERING
MON
TUE
WED
THU
FRI
SAT
SUN
BUNKER OPERATIONS At all times during bunkering, bunker stations should be manned and communication maintained with all parties with constant monitoring
Prior to bunkering in heavy rain, it is prudent to ensure that all free water is removed from decks and savealls
6 7 13 14 20 21 27 28
JUNE 2011
1 2 3 4 5 8 9 10 11 12 15 16 17 18 19 22 23 24 25 26 29 30
Visit to sick bay
MAY
30 2 9 16 23
31 1 3 4 5 6 7 8 10 11 12 13 14 15 17 18 19 20 21 22 24 25 26 27 28 29
JULY
4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28
1 2 3 8 9 10 15 16 17 22 23 24 29 30 31
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
BUNKERING KEEPER LEAVES THE GATE OPEN OPERATIONS
Gate operates automatically Sufficient personnel for
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
required operation
Emergency reporting/ Dart gun used by Zoo Keeper Dart Gun used by zookeeper communication procedures
MON
TUE
WED
THU
FRI
SAT
SUN
SLIPS, TRIPS AND FALLS Stores should always be verified and securely stowed on receipt. Access to cargo holds must never be left open unattended. Not only do they present a trip hazard, but also a security risk
4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28
Hug a Tree Day
1 2 3 8 9 10 15 16 17 22 23 24 29 30 31
AUGUST
Trip hazards should be marked and highly visible and not blend into the background
JULY 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
JUNE
6 7 13 14 20 21 27 28
1 2 3 4 5 8 9 10 11 12 15 16 17 18 19 22 23 24 25 26 29 30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
Obstructions, trip and Gate operates automatically fall hazards on VL clearly marked
Non-slip on all Gate has failure alarm walkways, working areas and ladders
Dart gun used by Zoo Keeper Dart Gun used by zookeeper Learning from incidents
COLLAPSED STOW
MON
TUE
THU
FRI
SAT
SUN
Containers should be in a good condition with doors closed and secure. An effective lashing system should be in place
Containers in a poor condition, or with unstable stow, should not be accepted. Cargo like this can cause incidents and loss of cargo overboard, for which the ship may be liable
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
sweatband fashion competition
AUGUST 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
JULY
4 5 6 7 11 12 13 14 18 19 20 21 25 26 27 28
1 2 3 8 9 10 15 16 17 22 23 24 29 30 31
CONTAINER/ CAR/RO RO Caged Tiger CARGO
SEPTEMBER
5 6 7 12 13 14 19 20 21 26 27 28
1 2 3 4 8 9 10 11 15 16 17 18 22 23 24 25 29 30
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
procedures
Securing/lashings
Dart gun used by Zoo Keeper Dart Use used by zookeeper Gun of third party assistance
MON
TUE
WED
THU
FRI
SAT
SUN
DEPLETED AIR BOTTLES Excessive numbers of engine starts/stops during manoevering will deplete pressure in the main engine start bottles which can result in loss of control of the vessel at critical times, such as when docking, due to the engine failing to start
5 6 7 12 13 14 19 20 21 26 27 28
SEPTEMBER 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
KEEPER LEAVES THE UNDER GATE OPEN
1 2 3 4 8 9 10 11 15 16 17 18 22 23 24 25 29 30
Be nice to officers day
AUGUST
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
OCTOBER
31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
NAVIGATION PILOTAGE
THIRD PARTY Emergency reporting/ Search Plan Search plan communication procedures Dart gun used by Zoo Keeper Dart Gun keeping/evidence Record used by zookeeper retention
MAULS OR KILLS PROPERTY MEMBER OF THE DAMAGE PUBLIC
collision
Competency of pilot
MONETARY COST
C5 C3
TANKER - CONTAMINATION
MON
TUE
WED
THU
FRI
SAT
SUN
TANK CLEANING Tanks should be thoroughly cleaned prior to loading. The photos above show a newly coated tank and one that is properly cleaned, although the coating is starting to break down
Above, bad tank cleaning with vegetable oil in a skip and all over the deck
31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Sweep fallen leaves from deck
OCTOBER 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
SEPTEMBER
5 6 7 12 13 14 19 20 21 26 27 28
1 2 3 4 8 9 10 11 15 16 17 18 22 23 24 25 29 30
TANKERS (CRUDE/ PROD/CHEM/GAS) Caged Tiger CARGO
NOVEMBER
7 14 21 28
1 2 3 4 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23 24 25 26 27 29 30
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
procedures
Dart gun usedkeeping/ Dart Gun used by Zoo Keeper Record by zookeeper evidence retention
MON
TUE
WED
THU
FRI
SAT
SUN
Are lessons learned from previous incidents Non conformity raised for incident Incident/Accident report correctly filled in Incident is raised at safety meetings and full crew meetings: - Discussion of what went wrong and how this can be avoided in future
Incident is discussed and appraised at Company level: - Actions to avoid future incidents are discussed and taken, improving barriers
Incident promulgated to full fleet to avoid duplication if possible Incident promulgated industry wide if appropriate to enhanced safety culture Full risk assessment undertaken to improve barriers/ controls in on board checklists Toolbox talks, job hazard awareness (JHA) systems and others as appropriate in all fleet vessels
7 14 21 28
1 2 3 4 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23 24 25 26 27 29 30
Wet deck skating competition
OCTOBER
NOVEMBER 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk takes only 5 minutes and is an essential tool in the management of risk at work.
31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
DECEMBER
5 6 7 12 13 14 19 20 21 26 27 28
1 2 3 4 8 9 10 11 15 16 17 18 22 23 24 25 29 30 31
Dart gun used by Zoo Keeper Dart Gun used by zookeeper Emergency drills/training
Emergency reporting/ Dart gun used by Zoo Keeper Dart Gun used by zookeeper communication procedures
Dart gun used by Zooto deal Dart Gun used crew Keeper Capability of by zookeeper with incident
Dart gun used by Zoo Keeper Dart Gun used by zookeeper Learning from incidents
GALLEY WORKING
MON
TUE
WED
THU
FRI
SAT
SUN
GALLEY ATTIRE Clean protective clothing should be worn at all times. Flip flops are not only bad hygiene, they offer no protection from scalds or from dropped objects and present a slip/trip hazard
Sleep
5 6 7 12 13 14 19 20 21 26 27 28
Sick bay
NOVEMBER
1 2 3 4 8 9 10 11 15 16 17 18 22 23 24 25 29 30 31
Party
More Party
GALLEY HYGIENE It is important to use clean, colour coded cutting boards and utensils, that have been properly disinfected. Dirty boards, cloths and surfaces can spread germs and cause cross contamination
DECEMBER 2011
GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work.
7 14 21 28
1 2 3 4 5 6 8 9 10 11 12 13 15 16 17 18 19 20 22 23 24 25 26 27 29 30
JANUARY 2012
30 2 9 16 23
31 1 3 4 5 6 7 8 10 11 12 13 14 15 17 18 19 20 21 22 24 25 26 27 28 29
Creating a bowtie diagram from the situation above there are many more barriers, can you find them?
Dart gun used by Zoo Keeper Dart Gun used by zookeeper Learning from incidents
For further information please contact: Loss Prevention Department, Thomas Miller P&I Ltd Tel: +44 20 7204 2307. Fax +44 20 7283 6517 Email: lossprevention.ukclub@thomasmiller.com