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IASS: Safety and Security for Passenger Ships and Offshore

Alexandria 19-20 October 2009

Risk management at Sea/Offshore

RISK Identification/Evaluation/MitigationCase: The capsizing of AH tug Bourbon

Dolphinwest of Shetland 12 April 2007, w.loss of 8

lives

by Arne Sagen, CNI, Safety Maritime AS

Accident Investigator/ISM Code Auditor/ISO Quality Assessor

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Offshore Anchor Handling tugs

The Norwegian AH-tug Bourbon Dolphins capsizing , April 2009:

The Accident Investigation Committe concluded:

Defects in Risk Assessment for the operational hazards Defects in the necesary safeguarding of relevant risks The Risk Assessment should include all external

hazards as tandem operation by command from the rig’s

towmaster Relevant shore personnel must be competent in Risk

Assm.

If the risks and hazards cannot be evaluated and controlle,d, the work should not be carried out”

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Offshore Supply and Anchor Handling

Internationall Rules and Regulations:

The ISM Code EU Standards for Safety and Health Oil Companys guidelines (NWEA, etc), Relevant National Regulations for S&H Private standards as ISO 9001, ISO 14001, HS 18001, IK-HMS, etc.

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The 3 main ISM Code objectives

1. ”To provide for safe practices and safe

working environment”

2.”To establish safeguards against all identified risks”

3. ”Continuously to improve the safety management skills….”

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Risk Assessment ”mini-manual”

Based upon Dr. W. Heinrich thesis (1931)

Modern Industrial Loss Prevention principles:

- The safety Culture- The understanding of accident causes- The six basic causes of unsafety- The six most common Human Errors- The seven ”job demands” - The two main causes of Accidents- The Accident distribution triangle (The Accident warning

system)- Hazard Identification and Risk Assessment- Etc. etc.

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The 6 basic quality elements:(=The ISM Code Functional Requirements)

1. Company Policy (*2. Written procedures (in compliance w. R&R)3. Defined levels of authority (incl. Company-ship)4. Procedures accident N-C reporting/handling5. Prepare for emergency situations6. Procedures for internal audits & man. Control

*) Including Policy for Risk Assessment

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The Safety Culture(The Human Factor)

We cannot imagine Safety and Healthto be achieved by means of

- PROCEDURES - INSTRUCTIONS

without the proper qualification ofpersonnel ashore and onboard, and:An adequate COMPANY STANDARD

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The loss causation model

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The 6 basic causes of ACCIDENTS 1. We think we deal with “facts” , but the “facts” often turns out to be false2. The level of observation is insufficient (or the level of taking decisions is wrong)3. The principle of “multiple causes” (Most accidents have usually a variety of contributing causes, w. has to be dealt with) 4. The principle of the “vital few” (Pareto principle: 80 % of the accidents is caused by 20 % of the employees) 5. The principle of simplification/less effort 6. The feeling of “it cannot happen to me”

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The 6 most common HUMAN ERRORS: 1. Change of working condition or organisation2. Accepts (to easily) unsafe conditions (style)3. Experience from different operation equipment (or different position/patterns)4. Poor information processing (Proper information, but wrong conclusion)5. Physical limitations (or lack of physical strength)6. Sensible to fatigue (Extreme work duration, stress, heat, cold, etc.)

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The 7 job demands :

1. Meaningful job content2. Need for variation3. Need for learning4. Need to make own decisions5. Need for support and recognition6. Feeling the job is socially accepted7. Need for future prospects

VSP twice a year - Min. 85 of 100 p. acceptable

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The 2 main causes of accidents:1. Personal factors (Unsafe acts of persons)Eks.: Operating without qualifications, failure in warning, Unsafe speed, safety devices inoperative Unsafe equipment, Unsafe placing, Unsafe position, Using dangerous equipment, Lack of personal protective equipment, etc. --------------------------------------------------------------2. Job factors (Unsafe mechanical/physical factors)Work place without guarding, Slippery, Unsafe design of tools, Inadequate lighting, Poor houskeeping, dangerous equipment, Personal protective equipment not in place, etc.

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Risk Assessment1. Identify all possible Risks/Hazards

2. Evaluate the risks and make plans for mitigation

(SEVERITY – FREQUENCY – PROBABILITY)3 Develop a more safe plan or

procedure (TTTT= Terminate/Treat/ Tolerate

/Transfer)

4. Implement the new plan5. Monitor and review

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Risiko Reduksjon (The “4 T procedure”) ------------------------------------1.Terminate the Risk (by replacement) 2. Treat the Risk (Change, modify) 3. Tolerate (Training/instruction/PPE) 4. Transfer (specialists/insurance/etc.)

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Risk Evaluation

.RISK AND HAZARD CLASSIFICATION

 

LOW HIGH

SEVERITY ○ ○ ○ X

PROBABILITY /FREQUENCY ● X ○ ○

DEGREE OF CONTROL ○ ○ X ○

COST OF CONTROL X ○ ○ ○

EXTENT OF APPLICATION X ○ ○ ○

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Risk Assessment

Safety and Health regulations

ILO-134: Prevention of Accidents

ILO-164: Health Protection and Medical Care

ILO-178: Concerning the inspection of Seafarer‘s Living and Working conditions

+++ Food and catering, Accommodations, Welfare, ships medicine, Med. Advice, etc.

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The Accident Warning systemHeinrich’s Accident Distribution Model

1 Serious accident

30 Minor accident

300 Near misses

3000 Unsafe acts/conditions

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Writing Procedures and Instructions

WHAT to do WHO shall do it WHEN shall it be done WHERE shall it be done HOW shall it be done WHY shall it be done

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Accident Investigation

1. Alle accidents have an immediate cause

Someting failed, or an error was done2. We must find the basic or core cause: Find the underlaying causes behind... 3. There are to categories of basic causes: A. Workplace condition B. Unsafe act of persons (Substandard act)

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Accident Investgation

A: Workplace conditions: Look at workplace arrangement, tools, light, space , view,

etc • - and do the necessary improvements

B: Personell-related errors:• Is there a procedure for the job or operation• Is the proceure adequate for the job or relevant person?• Is the proceure followed?

C: Is the company’s STANDARD satisfatory ?

All of these factors are the company’s responsibility

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The Quality/Safety Culture

1.Dictates how company operate(This is the way we are doing it here )

2 Decisive for how employees act and operate(Whether jobs will be done safely)

3. Demonstrates emplyees value to Quality/Safety(Incl. Performance and environment protection)

4. Indicate general business functions(Company Image within business sector)

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Quality training

Define or set the qualification requirement....

How do the candidate meet? Find the gap?

Evaluate the gap and set up a plan for the training

Execute the training Verifiy that the training have been

effective Verify that the candidate now meets the

required qualifications.

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CASE: Bourbon Dolphine

The capsizing of the Norwegian Anchor Handling vessel ”Bourbon Dolphin”, during an Anchor Handling operation, west of Shetland, the 12. April 1007.

8 lives lost.

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Case: Bourbon Dolphin

The Norwegian Accident Investigation Commissions reported:

The Commission failed to find the basic cause, but stated some 25 ”Key Conclusions”, as:

- Lack of shipsspecific Anchor Handling Manuals- Lack of training procedures in AH for relevant

officers- Lack of procedures for familiarising… - Lack of Risk Assessment procedures- The Rig Move Procedure was Incomplete- Risk Assessment should include external

operations

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Anchor Handling Tug Problems

In general, confusion about:1. Lack of specific requirements for AH vessels2. No international standard for Bullard Pull

rating (Power balance do not include use of

thrusters)”3. Confusion about the winch ”Emergency

Release4. Comfusion about the use of ”Rolldamping

Tanks” 5. (Should nor be used during Anchor Handling)6. Liferaft release is not functioning during

capsizing 7. Responsibility sharing for Towmaster and

Captain (The towmaster’s command, but captain’s

resp.ty)

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CASE: Bourbon Dolphin

The various open accident reports from the capsizing of the Danish ”Stevns Power” and the Norwegian ”Bourbon Dolphin” have been examined by a group of three:

Master Mariner Ian Clark, MSc, MNI (UK) AH Captain Michael Hancock, MNI (UK) Arne Sagen, Skagerrak Foundation, CNI

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Bourbon Dolphin:The probably 3 basic causes

1. The Girting effect

When the anchor chain’s ”point of attack” on the stern changes from the ships centreline (”offset”), the vertical forces from the anchor chain will cause a heling moment

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Bourbon Dolphin’s capsizing The probably 3 basic causes

2. The Free Trim Effect (AH vessel with

a short foreship and long/low deck):

When the ship is exposed to a large heeling condition, the buoyancy displacement distribution changes,

producing a stern trim effect

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Bourbon DolphinThe probably 3 basic causes

3. Thrusting force against the ”towline”

When the ships towline deviate from the ships centreline, the ship will be exposed to a horizontal force, causing a great heeling moment

NOTE: If the ship at the same time is exposed to a large thruster force, the ship may even ”roll over”

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Bourbon Dolphin: Learning lessons

========O VESSEL \ TOWLINE

\1.Never operate the AHV against the

towline2.If you do, do not use the thrusters to

right, as the vessel may ”roll over” the vessel3.Always operate the AHV with ahead trim

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AH Vessels: Learning lesson

1.Stability Compartments2.Monitoring of V&H forces

Stability towers for enhancing stability of an anchor handling tug

Stability towers at the outboard edges of the after deck

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Modern Anchor Handling operation by programmed

joystikNOTE:It is quite common for AH vessels that the

machinery has insufficient capacity for both propulsion and thrusting at the same time, and the thrusting force has prority before the propulsion power.

We are worry that such programming may contradict joystick order in a critical situation

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Bourbon Dolphin: Learning lesson

STORING OF LIFERAFTS ON VERTICAL PLATFORM

_UU___UU__

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I_______I Standard fitting of liferaft cannister

does NOT release and deploy the

liferafts by capsizing of the vessel ! (BD. I of 6)

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Admiral Joyn Lang, as Chief Inspector of UK Marine Accident Investigation Branch:1. The great number of accidents in the

shipping industry is caused by lack of competence

2. Accident Investigation in

shipping: Far too few of the accidents are

investigated by independent inspectors. The real and underlaying causes of whatever happened is often ignored or forgotten, with the risk that the same thing will l happen all over again.