Sep 102009
 

You cannot embed safe working practices in a crew if you don’t follow them yourself.

Luis Sokota, the Croatian Chief Officer of the UK registered containership Ville de Mars was undoubtedly set for celebration on 28 January 2009. It was his 34th birthday and the next day he was to leave the ship. Instead he died in the Royal Navy helicopter carrying him to hospital after he fell almost eight metres in a water ballast tank.

What makes his death even more notable than the sad and continuing tragedies in confined spaces is that he was the ship’s safety officer and died setting a bad example to the rest of the crew.

MAC has noted, particularly in The Case of the Silent Assassin, the potentially deadly results of crew following the bad practices of more senior officers. The example set by officers defines a ship’s safety culture, not training and certificates.

Luis Sokota was the ship’s safety officer and chaired the vessel’s weekly safety meetings. According to the MAIB report he was reported to have admonished crew who did not wear personal protective equipment when required.

During his time on board he had viewed 21 Videotel computer-based training modules including Working aloft on container ships and Personal safety on container ships – part 8. He had not viewed the module titled Confined Space Entry which was also available.

He fell to his death having not got either a permit to work aloft – and when you’re somewhere you can fall from you’re working aloft – or for confined space entry. Among the equipment required to work safely was a fall arrester. He didn’t wear one.

You cannot embed safe working practices in a crew if you don’t follow them yourself.

At the same time, if the shipowner doesn’t fix shortfalls in safety procedures, then the crew isn’t likely to take them seriously.

Although non compliance with the permit to work system had previously been identified during a company internal audit, no effective remedial action had been taken.

Here’s the MAIB synopsis:

On 28 January 2009, the chief officer on board the UK registered container ship Ville de Mars fell almost 8m when descending into a water ballast tank. The vessel was on passage in the Gulf of Oman. He was removed from the tank by the ship’s crew and died while being flown to a hospital ashore in Oman by a Royal Navy helicopter. The chief officer had been due to leave the vessel the following day in Jebel Ali, UAE. No postmortem was conducted.

The chief officer was not wearing a fall arrestor as he entered the ballast tank, and it is almost certain he slipped and fell from an un-guarded stringer. The precautions taken in preparation for his entry into the tank did not comply with the requirements of company procedures or industry practice. No permits to enter into an enclosed space or to work at height were issued. Although non compliance with the permit to work system had previously been identified during a company internal audit, no effective remedial action had been taken.

This is one of an increasing number of accidents which have resulted from complacency. Preventing this kind of behaviour at sea, where ship owners and managers are frequently thousands of miles from their vessels, is a huge challenge.

A recommendation has been made to CMA CGM Group aimed at identifying ways of combating complacency and instilling a positive safety culture on board its ships. It also aims to ensure that the methods identified are shared with the industry via the
MCA’s Human Element Advisory Group. A further recommendation has been made to CMA CGM Group aimed at improving the effectiveness of its internal vessel audit regime.

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