Jan 072009

MAC will be dealing with the MAIB report on the Saga Rose incident , released today, in which a second bosun died in a ballast tank, in a forthcoming podcast Many of the lessons are familiar but one in particular stands out – beware of change.

Joselito, the 43-years old second bosun aboard the cruise ship Saga Rose when it docked in Southampton, was tasked with finding out whether the water in a water tank was fresh or salty. To do that, he was asked to taste it, not a very healthy way to go around things but let that pass.

It was assumed that the tank he was to test was full so all he had to do was open the access, and reach in. He wouldn’t have to actually get into the tank so it was decided that no entry permit, or its safety procedures, was required. Joselito knew the procedures and had apparently followed them faithfully when entering such a space on previous occasions.

In fact, the tank was almost empty when Joselito looked through the access, so he climbed in to sample the water. The rest is an old story – rusting iron in the enclosed tank had sucked the oxygen out of the air and Joselito was almost certainly unconscious, and dying, within seconds of entering. A second seafarer, a close friend, attempted to rescue him with the proper equipment, fell unconscious as he tried to lift Joselito to safety, and was lucky to survive.

What happened was that the nature of the job changed, because there was less water in the tank than expected, from one supposedly requring no special permit to one that most definitely did but Joselito did not step back and review the circumstances of the task.

The lesson here is: if something about a job is different from what you expect then STOP, STEP BACK. Review the job, reassess the hazards and the procedures.

Always be conscious and wary of things that change, of jobs that don’t go according to plan. Don’t be so focussed on the end task that you forget to keep an eye on the bits in between.

Remember: When something changes, Stop. Step Back.

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