Special points of interest:

Please visit

www.stepchangeforsafety.com

Click

“VIEW SUBMISSIONS”

button on the home page to view

full details.

GLOBAL SHARING One industry Zero accidents

Volume 1, Issue 03

15th April 2013

INSIDE THIS ISSUE:

Finger Injury 2

Finger Injury 2

Head Injury 2

Pollution Averted 3

Pollution Alleged 3

Pilot Ladders 3

Best Practice – 4

( Good example of an

Incident Analysis)

Shell Maritime Contractor Safety Conference in Singapore

ONE INDUSTRY, ZERO ACCIDENTS

GOAL ONE-ZERO

SHIPPING TO BE SEEN AS A ROLE MODEL

LEADERSHIP - WALK THE TALK

PASSION FOR SAFETY THROUGHOUT THE MARITIME INDUSTRY

SAFETY CULTURE ACROSS THE ENTIRE ORGANISATION AND INDUSTRY

EMPOWERED, MOTIVATED, PROUD, COMPETENT AND TRAINED STAFF

COLLECTIVE CARE - TAKING SELF PRESERVATION TO OUR COMMUNITY

LESS NEED FOR POLICING AND

MICRO MANAGEMENT

ACTION POINT SEVEN

The involved participants share their experiences, good or

bad, so that all others can learn from these.

Action Point Seven Team Members

Mr. John Krousouloudis from Shell UK and team members

Capt Prashaant Mirchandani, Gurcharan Sachdeva,

Matthew Alexander, Alex Chow, Capt Rohit Sindhwani, Capt

Surendra Dutt, Capt Rajalingam Subramaniam and Mr. T

Miyamoto.

Step Change for Safety – A Shell Marine Initiative

STEP CHANGE FOR SAFETY

The movement initiated by Dr Grahaeme

Henderson continues to gathers steam in

Singapore.

We have surpassed our target of submissions

(of 10 per month) by 50% and, in the last three

months, have 48 submissions coming from

the Industry.

A big thanks to all of you supporting this

initiative and we look forward to your

continued involvement.

Photo (taken from the net)

page 2

“Routine jobs done

routinely still require a

fresh risk assessment and

hazard identification.

Having done similar jobs

many times before does

not make them any safer”.

THE INCIDENT

On one of the vessels, the

deck seaman / OS suffered

lacerations when his finger

got caught between the

flexible hose and aft

bulwark during manual

transfer of the hose. The

OS lost his footing and tried

to hold onto the bulwark to

balance himself, when his

finger got caught. Prompt

first aid was administered

and he returned to work

shortly thereafter.

Injury: Finger Injury during manual handling of cargo hose.

LESSONS LEARNT

Poor risk assessment

led to improper usage

of hand protection as

the OS was using

ordinary cotton

gloves instead of

heavy duty work

gloves provided to

vessel.

THE ACCIDENT

A wiper assisted a No.1 oiler

to drill a hole on the steel

plate in the engine room

workshop.

The No.1 oiler had lifted the

drill up still keeping on

rotation for adjusting

position of the steel plate.

Injury: Finger Injury during routine maintenance

The wiper suddenly put his

right hand near drill rotating

parts for assistance without

care. After a short while, his

cotton work glove got jammed in rotated drill and

he unfortunately lost tip of his

index finger.

LESSONS LEARNT

1) Company’s working

procedures shall be well

acquainted with and strictly

followed before carrying out

a task.

2) The workers in short

career were relatively

inexperienced for his task

and this should have been

identified as one of potential

hazards during risk analysis

3) Regular education for

encouragement of safety

consciousness shall be

strictly carried out for

seamen.

THE INCIDENT

While assisting the provider

to unload stores on the

wharf, an IR was struck on

the head and knocked to the

ground by the removable

door of the container which

FLEW off the truck with wind

gust. The IR was wearing a

hard hat which prevented

bigger injury.

Injury: Head injury from UFO (unrecognized flying object)

Lessons learnt

The incident highlights the need

for proper PPE at work at all

times

A thorough TAKE 5 missed out

the potential of door blowing off

the truck. Always ask yourself –

“WHAT CAN GO WRONG” and

“WHERE IS THE POTENTIAL

FOR SOMETHING TO FALL,

PINCH, STRAIN, FLASH, TRIP

ETC.”

Submitted

by: withheld.

GLOBAL SHARING

SAFETY TIPS TO AVOID HAND

AND FINGER INJURIES

KNOW the hazards and dangers in the

job to be done.

BE AWARE of pinch points, hot areas,

rotating or moving surfaces.

BE ALERT on the line of fire, avoid

clothing and jewellery which may get

caught in moving machinery

NEVER remove machine safeguards or

operate machinery without guards.

Submitted

by: withheld.

Submitted

by: withheld.

SAFETY TIPS TO AVOID FINGER

INJURIES DURING EQUIPMENT

HANDLING

USE TAGLINES, WEAR SUITABLE

HAND GLOVES, NEVER PLACE

YOUR HAND ON TOP OF LOAD OR

BETWEEN THE LOAD AN OBJECT,

INSPECT HOOKS AND CHAIN

SLINGS BEFORE USE, NEVER HANG

A LOAD FROM THE HOOK TIP.

THE INCIDENT

During start of transfer of LSFO

through hose from mother ship to

daughter ship the high back pressure

along with no flow was investigated.

The line-up was found correct. Further

investigation revealed choking of

flexible hose of daughter ship.

Operation suspended. The hose has

last been used for transfer of Rabi

Crude heated at 48 deg C.

Pollution averted: Lining damaged inside flexible hoses

FINDINGS

The inner lining of flexible hose of

daughter ship was torn about 2 feet

from flange end.

MESSAGE TO INDUSTRY

CHECK equipment prior to operation.

ENSURE all hoses are flushed and

drained dry after use.

IMPLEMENT stop work policy

PAY caution with heated cargo

HOSE INTERNAL LINING DAMAGED

FINDINGS

communication solo.

LESSON LEARNT

SUBMITTED BY –Name withheld by request.

THE INCIDENT

Alleged Oil Pollution during

Hose Disconnection at one of

Oil Major Terminal in USA.

An MR Tanker completed

discharging, sailed from the

Berth to anchor on Roads for

Bunkering. While Bunkering,

vessel received a notice

from USCG alleging that the

MR Tanker had caused

minor spill during Hose

disconnection.

Pollution alleged: Hose connection / disconnection in USA

FINDINGS

Investigations revealed that

the Crane Operator had

reported to USCG. He

claimed that the Blank on the

Hose was not fully tightened

even though the entire Hose

disconnection operation was

conducted under direct

supervision of the Berth

Master. No Spill or Oil Sheen

was noted in the water by all

Ship and Shore crew or Pilot

on the Bridge.

LESSONS LEARNT 1. During Hose connection /

Disconnection, pay attention to the Hose till fully connected on board

or until swung out and landed on the berth. 2. Ensure that the

packing is in good condition before putting the blank and all Bolts are

tightened appropriately before the hose is lifted from the vessel's

Manifolds. 3. Repeated Training to the crew for all aspects of Oil

Transfer procedures including the Cargo Hoses connection /

Disconnection must be followed and recorded.

MESSAGE TO INDUSTRY 1.Vessel can still be held

responsible for any negligence during the Oil Transfer Operations

including Connecting / Disconnecting of Hoses. 2. Even a minor

incident like this can tarnish the image of an Operator towards the

world class Charterers and the Oil Majors whose terminals are being

used or whose cargo is being carried on board.

THE INCIDENT

During 2012, there were three

cases of pilot ladder failures at a

major port in Asia.

FINDINGS

Investigations revealed that the

failures were caused by

degradation of the fiber rope at

the point where the rope goes

through the wooden battens.

The ropes had perished in this

area due to damp conditions

Property damage: Wet Rot in Pilot Ladders

where ladders were kept

covered under canvas allowed

“DAMP ROT” to set in and

destroy the ropes.

MESSAGE TO INDUSTRY

Ship Masters should ensure that

Pilot ladders are laid out to dry

after use.

Inspect Inner cores for “WET

ROT” regularly by twisting apart

the ropes prior use.

page 3 GLOBAL SHARING

Submitted by:

withheld

This submission from one of the participants deserves to be on the back cover of this newsletter due to its

thoroughness, simplicity of presentation and findings. I am sure you will agree with me. Cheers.

The above is a small selection of submissions from participants. Please visit the web-site

www.stepchangeforsafety.com for full details and to submit your entries or send us your much valued feedback.

Best Practice – Importance of good analysis of Incidents etc.

This Safety Bulletin is circulated with the sole purpose of sharing of

incidents, Near Misses, good practices and lessons learnt across the

marine and off-shore industry. Submissions are voluntary. No information

given here is to be used for any commercial gains or for any derogatory

purposes.

The views expressed here are from the contributors and do not represent

the official view of their company or Shell Marine in any way.

Please feel free to send your feed-back.

INDUSTRY

page 4 GLOBAL SHARING

GOAL

ONE-ZERO

A SHELL MARINE SAFETY INITIATIVE