MSC Siena MOB Fatality: When The Routine Became Risky

 Accident, Accident report, containership, weather  Comments Off on MSC Siena MOB Fatality: When The Routine Became Risky
Feb 112013

sienaRoutine is risky. Over the previous two months the crew of the containership MSC Siena had rigged the pilot ladder 30 times. The 31st time, on 17 November 2011 off Fremantle, a man was lost. No risk assessment had been done to take account of the weather conditions says Australia’s Transport Safety Board, ATSB, report on the incident.

The account is harrowing: “At about 1123, as the bosun watched the OS, he saw a ‘large wave suddenly rise up’ and strike the underside of the bottom platform of the accommodation ladder with force (the rope lashing the ladder to the shipside lugs parted). A loud bang was heard on deck and the bosun then saw the OS hanging from his harness rope, under the accommodation ladder’s bottom platform. Seeing that the OS had fallen off the ladder, the bosun began yelling.

“On hearing the yells, the seaman and the cadet looked over the side and saw the OS suspended about 1 m below the bottom platform. He was shouting for help while trying to hold on to the lower part of the pilot ladder. His legs were often submerged in the rough seas which were pounding his body against the ship’s side, the platform and the pilot ladder, and repeatedly breaking his hold on the ladder. Continue reading »

Oct 092011

“Complacency” is a term much bandied about after accidents. It implies some deliberate act of decision or non-decision that consciously says “It won’t happen to me” but the latest issue of Nature Neuroscience, reports the BBC, suggests that the lack of appreciation of risk is inherent and not a result of conscious processing.

Research carried out at University College London showed that risk assessments were poor in four out of five people, with the brain filtering out potentially negative future outcomes. Faced with real-life statistics, the assessment of potential negative outcomes changed marginally.

The negative outcomes are not being consciously suppressed, any more than a sieve consciously suppresses objects too big to pass through its mesh.

This work goes well with research that shows that the brain filters data that it has evolved to ignore. Slow changes in the environment are filtered before they reach the consciousness, for instance. Fast changes may not be noticed even if we are consciously looking for them.

It doesn’t feel like that but the truth is that while we may be the CEOs of our brains, our brains are like secretaries who only tell us what they want us to know, which is not necessarily what we need to know.

The relevance to safety is obvious. Less obvious, though, may be the need to understand these hard-wired hazards to understanding risks.


Sod’s Laws, Doors and Compressed Air

 maritime safety news, safety alert, Safety Alerts  Comments Off on Sod’s Laws, Doors and Compressed Air
Jan 112011

However low you think the chances of someone walking through a door at precisely the same moment you’re using compressed air and chemicals to clear the pipe next to the door and spitting debris and hazardous chemicals into someone’s face, it is not low enough. That most predictive of all scientific principles, Sod’s Law (Murphy’s Law in the US) says that it will happen.

Here’s a safety alert from Marine Safety Forum:

Continue reading »

Nov 172010
scaffolding_fig 5

The deadly scaffold

Three key lessons arise from the Australian Transport Safety Bureau investigation into the fall of a scaffold in a cargo hold aboard the Panama-registered bulk carrier United Treasure: Make sure all safety-critical parts of the structure are in place; ensure the the scaffold is properly secured against falling over; don’t attach fall preventers to the scaffold.

On 7 July 2009, while United Treasure was anchored off Port Kembla, New South Wales, two seamen fell about 8 metres in a cargo hold after the scaffolding on which they were working toppled over. Both men suffered compound fractures and were evacuated from the ship by helicopter and taken to hospital.

Continue reading »

MAIB Safety Digest – Risk Assess Now – Before You Learn The Hard Way

 Maritime Accident, maritime accidents, Maritime Investigation, maritime safety, news  Comments Off on MAIB Safety Digest – Risk Assess Now – Before You Learn The Hard Way
Nov 302009

imageRisk assessments, often, and unwisely, seen as little more than mere paperwork by busy seafarers are the focus of MAIB Chief Inspector Stephen Meyer in his introduction to the latest MAIB Safety Digest.

Writes Meyer: “It is only a year since I last wrote about the importance of risk assessments. However, in the past 12 months, so many deaths have been reported that could have been avoided by a simple consideration of the risks, that I feel compelled to return to the subject.

Just the phrase “risk assessment” is enough to cause most mariners’ eyes to glaze over. “More paperwork and bureaucracy” I hear you cry. But what I am after is the thought process, not the paperwork. Let me give you a couple of examples.

Continue reading »

Safety Alert – MOB, Lifejackets, Hazard Assessment and Wear

 maritime safety, Safety Alerts  Comments Off on Safety Alert – MOB, Lifejackets, Hazard Assessment and Wear
Sep 072009


At about 1308 on 12 February 2009, a deckhand on board the UK registered scallop dredger Maggie Ann fell overboard as he was emptying a dredge bag. He had been standing on the port dredge beam, which was suspended and almost level with the gunwale, when the dredge bag lifting becket parted.

The deckhand was not wearing a personal flotation device or a safety harness when he stepped onto the elevated dredge beam, and it was not the practice for deckhands to do so. On this occasion, he let go of the suspension chain to facilitate his emptying one of the dredge bags. As he grasped the dredge bag with both hands, the lifting becket parted, causing him to fall forward and with no protection from the bulwark, to continue to fall overboard.

Continue reading »

Finger Chopper Match Results: Second Engineer 2, Fan 3

 Uncategorized  Comments Off on Finger Chopper Match Results: Second Engineer 2, Fan 3
May 212008

It was a routine task which left the second engineer three finger short after an encounter with a fan.

The MSF safety flash goes thusly:
A Second Engineer was taking a water sample from the air cooler radiator of an air compressor. He was closing the drain sample point using a spanner held in his left hand and had his right hand on the cooling fan guard at a point where there was a gap in the guard. At that moment the compressor started on auto start. Unfortunately he lost the 3 middle fingers of his right hand.

Lessons learned:
• The guard was not complete around the cooling fan as a small segment had been left for maintenance purposes. This does not appear to have been recognised as a hazard before this accident. Ships management and external inspectors should ensure a critical look is taken at work places during area inspections to identify such hazards.

• The sample drain under the radiator pointed towards the compressor when it could easily have been turned 180 degrees so it could be accessed from a safer position in front of the radiator.

• The isolation of this compressor was not consistently done when water samples were taken on a routine basis. There was no risk assessment or job card to highlight isolation during water sampling.

• It might also be considered that isolating machinery in such a case should be standard engineering practice.
• Chief Engineers should satisfy themselves that the correct level of supervision is in place for all tasks in machinery spaces.

• Routine tasks should receive proper care and attention. Where formal risk assessments are not considered necessary it may be prudent to develop work routines or job cards which state the controls which are required. The Step Change in Safety “Task Risk Assessment Guide” contains useful advice on this.