OPTIMISM Training Platform

Table 16: Micro Presentation of a Review of an Accident – Review 2

 

Title: An Investigation into Root Causes of Accident – Entering Enclosed Spaces

Accident Investigation Review 2 - Enclosed Spaces

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by a leading Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed a systematic approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

C4FF Accident 2 (9244386) - While chief officer (C/O) was checking the cleanliness of the empty tanks prior to loading cargo at the next destination port, he discovered dampness and residue remaining inside one of the tanks and decided to remove them with support from the bosun and two ordinary seamen (OS), A and B without having conducted gas freeing or checking oxygen and gas levels beforehand and without carrying a portable detector or wearing personal protective equipment (PPE). The OS A felt drowsy and dizzy and noticed OS B lying on the floor at the bottom of the tank. Bosun was informed and the incident was reported to C/O. Later, OS B recovered but the C/O did not.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

The investigation report identified instances where Shipping company must constantly provide training programs for crew members so that they do not let their experience, practices, and work efficiency concerns override the need to be safe in confined spaces. The shipping companies, too, need to maintain strict guidance and supervision through internal audits.

5. Observations 

A review of the investigators report show that there was a non-compliance viz., entering enclosed spaces without having conducted gas freeing or checking oxygen and gas levels beforehand and without carrying a portable detector or wearing personal protective equipment (PPE) – There was an inappropriate policy manual, inappropriate procedures, inadequate supervision, problems with safety culture and inadequate leadership of operational tasks, including a lack of correction of unsafe practices. Furthermore, there was evidence of inadequate risk assessment, inadequate team composition, inadequate leadership, inadequate Knowledge, inadequate competence/skills and incorrect perception.

6. Comments

It is difficult to imagine that all these deficiencies were the result of a mistake. How would it be obvious to an observer that there was a means available for checking oxygen and gas levels and were the crew trained on freeing gas and using a portable detector, and the latter properly maintained and the crew were trained on using it correctly and in accordance with the Manufacturer’s instructions. The same can be stated about the PPEs.