Safety study for mariners at work on ships.pptx

safety study for mariners at work on ships.

1. SAFETY STUDY

2. Fatal crush incident – CASE STUDY

3. Fatal crush incident

4. B ACKGROUND A general cargo ship was berthed alongside and loading a cargo of cement. The 2/O came on watch shortly before midnight and at 0115 the cargo loading was competed. The 2/O remained on duty until 0540, when the C/O took over the watch again. After 0830, the C/O started to close the pontoon-type hatch covers using the ship’s gantry crane and instructed the deck crew to commence cleaning cement dust from the coamings. These tasks had to be completed before departure. At about 0900, the agents informed the master that the sailing time had been brought forward. The C/O advised the master that all available hands would be needed to complete the cleaning including the 2/O. Fatal crush incident Starboard walkway looking forward showing stack of hatch covers and gantry crane Source: Marine Accident Investigation Branch (MAIB), © Crown copyright, 2020

5. THE INCIDENT The 2/O arrived on deck at about 0930 and began sweeping dust from the aft cargo hold hatch cover landing surface on the stbd side. The two ABs and deck cadet were on deck sweeping dust from the hatch covers and coaming. They were wearing face masks and eye protection, but the 2/O and C/O were not. The C/O remained on the gantry crane, moving hatch covers. At 0942, the C/O moved a cover to the forward end of the forward hold. At 0943, he drove the gantry crane aft. At the same time, the 2/O finished sweeping and started to walk forward along the walkway. At 0944, the C/O stopped the crane just short of a stack of hatch covers at the forward end of the aft hold and started raising the lifting bar. The 2/O arrived at the forward end of the hatch cover stack and climbed onto the hatch coaming. Fatal crush incident Zoomed closed-circuit television (CCTV) screenshot looking forward showing the 2/O climbing onto the cargo hold hatch coaming Source: Marine Accident Investigation Branch (MAIB), © Crown copyright, 2020

6. THE INCIDENT (continued) As the 2/O stepped towards the gap between the crane and the stacked hatch covers, the lifting bar cleared the hatch cover stack and the C/O drove the crane aft. The 2/O screamed as he was trapped and crushed between the hatch covers and the crane’s ladder access platform. The crane stopped abruptly and the C/O immediately reversed the crane. As the crane moved forward, the 2/O was rolled between the crane’s ladder platform and the hatch covers and he then fell off the coaming onto the walkway below. As he fell, he struck his head on the guardrails on the side of the walkway. Reacting to the 2/O’s screams, the ABs and the deck cadet rushed to the scene. The 2/O soon lost consciousness and stopped breathing and the deck crew immediately commenced cardio-pulmonary resuscitation (CPR). Fatal crush incident Reconstruction showing a crew member in the gap between the ladder platform and stacked hatch covers Source: Marine Accident Investigation Branch (MAIB), © Crown copyright, 2020

7. THE INCIDENT (continued) The C/O called the master on his radio and informed him that the 2/O had fallen. The master made his way to the scene within a minute, then called the ship’s agent, who alerted the emergency services. The master also called the Designated Person Ashore (DPA) and told him that the 2/O had fallen on deck. At about 1005, two emergency medical teams arrived and the C/O told them that the 2/O had fallen from the coaming. Despite the efforts of the medical teams, the 2/O was declared deceased at 1100. The attending doctor told the master and C/O that the 2/O had possibly died as a result of a heart attack. Fatal crush incident

8. THE INCIDENT (continued) The post mortem report concluded that the 2/O had experienced a violent accidental death, resulting from internal bleeding due to organ rupture. He had also suffered multiple fractures. The 2/O’s toxicology report stated that his blood alcohol content (BAC) was 117mg per 100ml. The incident occurred on the 2/O’s birthday. The investigation noted that an emergency stop button was fitted to the crane platform, but the 2/O would have been unable to reach this while in the gap between the platform and covers. Fatal crush incident Access to starboard emergency stop button Source: Marine Accident Investigation Branch (MAIB), © Crown copyright, 2020

9. R EFLECTIVE LEARNING The questions below are intended to be used to help review the incident case study either individually or in small groups: What do you think was the immediate cause of the incident? What other factors do you think contributed to the incident? What do you think were the barriers that should have prevented this incident from occurring? Why do you think these barriers might not have been effective on this occasion? What risk assessments and procedures are available for the use of moving machinery, such as gantry cranes, on your ship? Do these identify the risk of entrapment and / or crushing of personnel? What warning devices are fitted to the moving machinery, such as gantry cranes, on your ship? Do you believe these are effective and adequate to mitigate the identified risks? Who are the authorised operators of any lifting equipment on your ship? What training have they been provided with? What training have other crew members been provided with in the risks associated with the use of the lifting equipment? What is your company’s Drugs and Alcohol policy? In light of this incident, what are your views on the policy? Fatal crush incident

10. L ESSONS LEARNED The following lessons learned have been identified based on the available information in the investigation report and are not intended to apportion blame on the individuals or company involved: Incident cause – The 2/O was crushed while he was trying to walk between the gantry crane and a stack of hold hatch covers when the C/O began to move the gantry crane aft at the same time. This reduced the gap between the crane’s ladder platform and covers to around 130mm, trapping the 2/O. Communication – The 2/O was unaware that the C/O was about to move the crane, while the C/O was unaware that the 2/O was under the crane and about to climb through the gap. The 2/O’s and C/O’s situational awareness would have been enhanced if effective communications had been established and the deck operations had been properly controlled. Situational awareness – Once the 2/O was within a couple of metres of the crane, he would not have been visible to the C/O at the gantry control position. Before moving the crane, the C/O should have moved from the crane’s control position to check the walkways and ensure the area directly below was clear. Crane warning devices – The gantry crane was fitted with a loud warning bell and flashing amber light, but these only operated while it was moving. The 2/O would have been alerted to the crane’s imminent movement if it had been fitted with a pre-movement warning device. Fatal crush incident

11. L ESSONS LEARNED The following lessons learned have been identified based on the available information in the investigation report and are not intended to apportion blame on the individuals or company involved: Emergency stops – The crane’s deck level emergency stop buttons could only be operated from the walkways and could not be reached by the 2/O before and after he became trapped. Risk Assessment/Procedures – The risk assessment and procedure for operating the gantry crane could have been clearer. However, the incident would have been avoided if the stated safety controls had been implemented. Safety Culture – The onboard safety culture was weak, as established safe systems of work were not being followed, personnel were working close to moving equipment and unprotected edges, and were not wearing adequate PPE. Alcohol use – The 2/O’s judgment and perception of risk were probably adversely affected by alcohol. The company’s drug and alcohol policy allowed the crew to drink in moderation provided they were always under the legal limit. However, this policy was not being effectively enforced. Initial incident communication – The medical personnel were not informed of the full circumstances of the 2/O’s injuries, but it is unlikely that this affected his survival chances. All known details of an incident should always be communicated to ensure the most appropriate medical treatment can be provided. Fatal crush incident

12. Fatal crush incident

13. C ONCLUSIONS The circumstances of this incident highlight the significant dangers associated with moving machinery on ship’s decks. Travelling gantry cranes tend to be particularly hazardous, due to factors such as the limited space available, restricted visibility and the noisy environment. The 2/O was an experienced seafarer and should have been well aware of the hazards and established safe practices while working on deck in way of the gantry crane. It is possible that a combination of tiredness, the alcohol in his bloodstream and the complacency associated with the familiarity of working on deck in the vicinity of the gantry crane affected his judgment in deciding to climb through the gap between the crane and the covers. Both the 2/O’s and C/O’s situational awareness would have been enhanced if the deck operations had properly been controlled, and effective communications had been established and maintained at all times. Fatal crush incident

14. C ONCLUSIONS Although the risk assessment for opening and closing the hatch covers using the gantry crane did not specifically identify the risk of crushing, the incident should nevertheless have been avoided if the included safety critical control measures had been implemented. This incident serves as a stark reminder that excessive alcohol consumption and working on deck do not mix, and significantly compromises the safety of the affected individuals as well as their fellow crew members. Fatal crush incident

15. PRO action versus RE action “Well that’s an accident waiting to happen…” “Someone ought to do something…” That someone is YOU !

16. Accident Prevention

17. "That Was Close" "Just Missed !" "Whhoooaaa!" # ! @ # *% ! Near Miss "Watch Out" Almost Hit L U C K Y What Is An Accident?

18. An Accident is: An unexpected and undesirable event, especially one resulting in damage or harm

19. Hazard Existing or Potential Condition That Alone or Interacting With Other Factors Can Cause Harm A Spill on the Floor Broken Equipment

20. Risk A measure of the probability and severity of a hazard to harm human health, property, or the environment A measure of how likely harm is to occur and an indication of how serious the harm might be Risk  0

21. Safety FREEDOM FROM DANGER OR HARM Nothing is Free of BUT - We can almost always make something SAFER

22. Safety Is Better Defined As …. A Judgement of the Acceptability of Risk

23. R A T I O S

24. OSHA METHOD 330 Incidents 29 Minor Injuries 1 Major or Loss-Time Accident

25. Types of Accidents FALL TO same level lower level CAUGHT in on between CONTACT WITH chemicals electricity heat/cold radiation BODILY REACTION FROM voluntary motion involuntary motion

26. Types of Accidents (continued) STRUCK Against stationary or moving object protruding object sharp or jagged edge By moving or flying object falling object RUBBED OR ABRADED BY friction pressure vibration

27. Accident Causing Factors Basic Causes Management Environmental Equipment Human Behavior Indirect Causes Unsafe Acts Unsafe Conditions Direct Causes Slips, Trips, Falls Caught In Run Over Chemical Exposure

28. Policy & Procedures Environmental Conditions Equipment/Plant Design Human Behavior Slip/Trip Fall Energy Release Pinched Between Indirect Causes Direct Causes ACCIDENT Personal Injury Property Damage Potential/Actual Basic Causes Unsafe Acts Unsafe Conditions

29. Basic Causes Management Environment Equipment Human Behavior Systems & Procedures Natural & Man-made Design & Equipment

30. Management Systems & Procedures Lack of systems & procedures Availability Lack of Supervision

31. Environment Physical Lighting Temperature Chemical vapors smoke Biological Bacteria Reptiles

32. Environment

33. Design and Equipment Design Workplace layout Design of tools & equipment Maintenance

34. Design and Equipment Equipment Suitability Stability Guarding Ergonomic Accessibility

35. Human Behavior Common to all accidents Not limited to person involved in accident

36. Human Factors Omissions & Commissions Deviations from SOP Lacking Authority Short Cuts Remove guards

37. Competencies (how it needs to be done) Human Behavior is a function of : Activators (what needs to be done) Consequences (what happens if it is/isn’t done )

38. ABC Model A ntecedents (trigger behavior) B ehavior (human performance) C onsequences (either reinforce or punish behavior )

39. Only 4 Types of Consequences: Positive Reinforcement (R+) ("Do this & you'll be rewarded") Negative Reinforcement (R-) ("Do this or else you'll be penalized") Behavior Punishment (P) ("If you do this, you'll be penalized") Extinction (E) ("Ignore it and it'll go away")

40. Consequences Influence Behaviors Based Upon Individual Perceptions of: Timing - immediate or future Consistency - certain or uncertain Significance { Magnitude Impact positive or negative

41. Human Behavior Behaviors that have consequences that are: Soon Certain Positive Have a stronger effect on people’s behavior

42. Some examples of Consequences:

43. Why is one sign often ignored, the other one often followed?

44. Human Behavior Soon A consequence that follows soon after a behavior has a stronger influence than consequences that occur later Silence is considered to be consent Failure to correct unsafe behavior influences employees to continue the behavior

45. Human Behavior Certain A consequence that is certain to follow a behavior has more influence than an uncertain or unpredictable consequence Corrective Action must be: Prompt Consistent Persistent

46. Human Behavior Positive A positive consequence influences behavior more powerfully than a negative consequence Penalties and Punishment don’t work Speeding Ticket Analogy

47. Human Behavior Example: Smokers find it hard to stop smoking because the consequences are: A) Soon (immediate) B) Certain (they happen every time) C) Positive (a nicotine high) The other consequences are: A) Late (years later) B) Uncertain (not all smokers get lung cancer) C) Negative (lung cancer)

48. Deviations from SOP No Safe Procedure Employee Didn’t know Safe Procedure Employee knew, did not follow Safe Procedure Procedure encouraged risk-taking Employee changed approved procedure

49. Human Behavior Thought Question: What would you do as a worker if you had to take 10-15 minutes to don the correct P.P.E. to enter an area to turn off a control valve which took 10 seconds?

50. Human Behavior Punishment or threatening workers is a behavioral method used by some Safety Management programs Punishment only works if: It is immediate Occurs every time there is an unsafe behavior This is very hard to do

51. Human Behavior The soon , certain , positive reinforcement from unsafe behavior outweighs the uncertain , late , negative reinforcement from inconsistent punishment People tend to respond more positively to praise and social approval than any other factors

52. Human Behavior Some experts believe you can change worker’s safety behavior by changing their “Attitude” Accident Report – “Safety Attitude” A person’s “Attitude” toward any subject is linked with a set of other attitudes - Trying to change them all would be nearly impossible A Behavior change leads to a new “Attitude” because people reduce tension between Behavior and their “Attitude”

53. A re inside a person’s head -therefore they are not observable nor measurable Attitudes can be changed by changing behaviors however Attitudes

54. Human Behavior “Attention” Behavioral Safety approach Focuses on getting workers to pay “Attention” Inability to control “Attention” is a contributing factor in many injuries You can’t scare workers into a safety focus with “Pay Attention” campaigns

55. Reasons for Lack of Attention 1. Technology encourages short attention spans (TV remote, Computer Mouse) 2. Increased Job Stress caused by uncertainty (mergers & downsizing) 3. Lean staffing and increased workloads require quick attention shifts between tasks 4. Fast pace of work – little time to learn new tasks and do familiar ones safely

56. Reasons for Lack of Attention 5. Work repetition can lull workers into a loss of attention 6. Low level of loyalty shown to employees by an ever reorganizing employer may lead to: a) Disinterested workers b) Detached workers (no connection to employer) c) Inattentive workers

57. Human Behavior Focusing on “Awareness” is a typical educational approach to change safety behavior Example: You provide employees with a persuasive rationale for wearing safety glasses and hearing protection in certain work areas

58. Human Behavior Developing Personal Safety Awareness Before starting, consider how to do job safely Understand required P.P.E. and how to use it Determine correct tools and ensure they are in good condition Scan work area – know what is going on As you work, check work position – reduce any strain Any unsafe act or condition should be corrected Remain aware of any changes in your workplace – people coming, going, etc. Talk to other workers about safety Take safety home with you

59. Human Behavior Some Thought Questions: Do you want to work safely? Do you want others to work safely? Do you want to learn how to prevent accidents/injuries? How often do you think about safety as you work? How often do you look for actions that could cause or prevent injuries?

60. Human Behavior More Thought Questions: Have you ever carried wood without wearing gloves? Have you ever left something in a walkway that was a tripping hazard? Have you ever carried a stack of boxes that blocked your view? Have you ever used a tool /equipment you didn’t know how to operate? Have you ever left a desk or file drawer open while you worked in an area? Have you ever placed something on a stair “Just for a minute”? Have you ever done anything unsafe because “I’ve always done it this way”?

61. Human Behavior TIME! “All this safety stuff takes time doesn’t it”? “I’m too busy”! “I can’t possibly do all this”! “The boss wants the job done now”!

62. Human Behavior Does rushing through the job, working quickly without considering safety, really save time? Remember – if an incident occurs, the job may not get done on time and someone could be injured – and that someone could be YOU!!

63. OUTCOMES OF ACCIDENTS NEGATIVE OUTCOMES POSITIVE OUTCOMES

64. $ Direct Costs Medical Insurance Lost Time Fines

65. Compliance Failure to develop and implement a program may be cited as a SERIOUS violation (by itself or "Grouped" with other violations) Penalties (as high as $ 2,000) may be assessed

66. Compliance Up to 35% of the penalty can be deducted based upon an employer's "good faith“ - Good faith is based upon: Awareness of the Law Efforts to comply with the Law before the inspection Correction of hazards during the inspection Cooperation & Attitude during the inspection Overall safety and health efforts including the Accident Prevention Program

67. Indirect Costs Injured, Lost Time Wages Non-Injured, Lost Time Wages Overtime Supervisor Wages Lost Bonuses Employee Morale Need For Counseling Turn-over

68. Indirect Costs Equipment Rental Cancelled Contracts Lost Orders Equipment/Material Damage Investigation Team Time Decreased Production Light Duty New Hire Learning Time Administrative Time Community Goodwill Public/Customer Perception 3rd Party Lawsuits

69. “REAL” Costs

70. OUTCOMES OF ACCIDENTS POSITIVE ASPECTS Accident investigation Prevent repeat of accident Improved safety programs Improved procedures Improved equipment design

71. SIGNS!!!