Threats, incidents, controls and consequences calendar with humorous illustrations based on the UK Club s new risk assessment initiative.
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1 UK P&I CLUB Threats, incidents, controls and consequences calendar with humorous illustrations based on the UK Club s new risk assessment initiative. HAZARD THREAT Controls to contain threat and to stop incident Controls to reduce consequence after the incident CONSEQUENCE Controls INCIDENT Controls
2 WHAT IS RISK?
3 MON TUE WED THU FRI SAT SUN New Year s Resolutions v SNAP-BACK ZONES Highlighting snap-back zones ensures that crew can easily see danger areas without having to purposely think about them while working EMERGENCY EXITS All exits should be visible and clearly signed Doors should be functioning correctly and tested through regular maintenance JANUARY 2011 DECEMBER FEBRUARY Paint hazard areas Holiday! THE TIGER IN THE CAGE Although sixty per cent of UK Club claims are caused by human error, human error is often only the straw that breaks the camel s back the last event in a chain of causal events. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? CAGED Caged TIGER Tiger These causal events can normally be traced back to failures in one or more areas of ship operation, we sometimes refer to them as accidents waiting to happen. How can we reduce the frequency of these accidents waiting to happen. What controls should we be looking at to ensure the threat is contained and an incident does not occur? KEEPER LEAVES LEAVES THE THE GATE OPEN OPEN Gate operates Gate operates automatically automatically Gate has failure alarm Gate has failure alarm ZOO: Zoo: Tiger TIGER Escapes ESCAPES Search Plan plan Search plan Dart Dart gun Gun used Dart by by gun Zoo zookeeper Keeper used by zookeeper MAULS MAULS OR KILLS KILLS MEMBER OF THE OF PUBLIC C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
4 TOOLBOX TALKS
5 Toolbox talks and work planning meetings These are pre-work meetings held on board They should include, as far as practical to do so, the following: Risk assessment of operation to include the plan to be discussed and evaluated with the team members Safety matters, to include: -Discuss the job plan overall -What is the job, and procedure to follow -Who will do what -Discuss the safety rules for the area of work to be done What could go wrong Galley Clog DANCE MON TUE WED THU FRI SAT SUN What are the main hazards Assess the risks and how do you eliminate them Get all to participate to create ownership of safety in the job to be done and full safety awareness Ensure as far as possible all personnel understand the safety rules for the job to be done Remind all of the STOP procedure if the job changes (i.e. weather hazards, additional ropes required, winch problems, minor and major accidents should occur) 28 FEBRUARY 2011 JANUARY MARCH GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? WELDING AND Caged Tiger BURNING Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER HOT LEAVES WORKTHE GATE GENERAL OPEN Permit to work including Gate operates automatically checklist completion prior to job commencement Gate Toolbox has failure talks alarm and work planning meetings PERSONAL INJURY Zoo: Tiger Escapes HOT WORK: IGNITION Damage Search mitigation Plan plan procedures Dart Dart Emergency gun Gun used by by equipment Zoo zookeeper Keeper adequacy/availability PERSONAL MAULS OR INJURY KILLS MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
6 MOORING OPERATIONS
7 MON TUE WED THU FRI SAT SUN MOORING Using a split mooring winch correctly is essential. The top photo shows the correct use, with the warp in good condition. In the bottom phot, the warp has been left on the drum end and the mooring warps are spliced, seriously reducing their strength International Women s Day! Rope correctly stowed off deck Rope badly stored on wet deck MARCH 2011 FEBRUARY APRIL GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? MOORINGS UNDER TENSION/ Caged Tiger ROTATING MACHINERY Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. MOORING & KEEPER LEAVES THE UNMOORING GATE OPEN OPERATIONS Gate Houskeeping operates automatically standards maintained in all areas Trade competancy of Gate has failure alarm personnel to perform required duties PERSONAL INJURY MOORING/ Zoo: Tiger Escapes UNMOORING: LOSS OF CONTROL Search Plan plan Alarm/Stop procedures Dart Dart Capability gun Gun used of by crew by Zoo zookeeper to Keeper deal with incident PERSONAL MAULS OR INJURY KILLS MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
8 CARGO - WET DAMAGE
9 MON TUE WED THU FRI SAT SUN April Fools Day No FALLS Day HATCH COAMINGS In the good example above, the compression bar and drain channel are in good condition and the coaming is free of rust and other debris. Badly corroded compression bars and drainage channels are likely to damage latch lid rubbers and allow water to pass into the hold Hatch rubbers should be undamaged and clean, well packed and soft, so that they offer good compression and seal. Where rubbers are old, hard and cracked they can allow water ingression APRIL 2011 GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. MARCH Creating a bowtie diagram from the situation above there are many more barriers, can you find them? BULK/GENERAL/ Caged Tiger REEFER CARGO MAY Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER WET DAMAGE LEAVES THE GATE OPEN Gate operates automatically Weather routing Regular hose test/chalk Gate has failure alarm test or ultra sonic test on hatch covers CARGO B/G/R WET DAMAGE: Zoo: Tiger Escapes LOSS OR DAMAGE Damage Search mitigation Plan plan procedures Dart Dart gun Gun used by by Zoo zookeeper Keeper Learning from incidents MAULS DRY CARGO OR KILLS MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
10 COLLISION AVOIDANCE
11 MON TUE WED THU FRI SAT SUN May Day May Day? BRIDGE DISTRACTIONS Distractions are often the cause of groundings or collisions and are often caused by other duties or paperwork that need to be carried out by watchkeeping officers. Sometimes the distractions are of a more personal nature such as mobile phones and music systems. Bridge computers, used for performing routine duties, should not be used for entertainment or amusement PROPER PROCEDURES In some collisions or near misses, watchkeeping officers have shown a lack of knowledge of what to do in such emergancy situations. Familiarity with regulations and publications such as Rules of the Road is essential MAY 2011 APRIL JUNE GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? SHIP Caged IN TRANSIT Tiger Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER REDUCED LEAVES THE VISIBILITY GATE OPEN Proper lookout Gate operates automatically maintained at all times by all available means Gate Standing has failure and alarm night orders issued COLLISION REDUCED VISIBILITY: Zoo: Tiger Escapes COLLISION/ GROUNDING DAMAGE Search Plan plan Emergency drills/training Dart Dart gun Gun Use used of third by by Zoo party zookeeper Keeper assistance COLLISION MAULS OR KILLS OR MEMBER GROUNDING OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
12 POLLUTION - BUNKERING
13 MON TUE WED THU FRI SAT SUN BUNKER OPERATIONS At all times during bunkering, bunker stations should be manned and communication maintained with all parties with constant monitoring Prior to bunkering in heavy rain, it is prudent to ensure that all free water is removed from decks and savealls Chef s cordon bleu food day Visit to sick bay JUNE 2011 MAY JULY GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? POLLUTION Caged Tiger Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER BUNKERING LEAVES THE OPERATIONS GATE OPEN Gate Sufficient operates personnel automatically for required operation Gate has failure alarm Scupper plugs in place POLLUTION BUNKERS: Zoo: Tiger Escapes LOSS OF CONTAINMENT Search Plan plan Alarm/Stop procedures Dart Emergency Dart gun Gun used by by reporting/ Zoo zookeeper Keeper communication procedures MAULS POLLUTION OR KILLS MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
14 SLIPS, TRIPS AND FALLS
15 MON TUE WED THU FRI SAT SUN SLIPS, TRIPS AND FALLS Stores should always be verified and securely stowed on receipt. Access to cargo holds must never be left open unattended. Not only do they present a trip hazard, but also a security risk Hug a Tree Day Trip hazards should be marked and highly visible and not blend into the background JULY 2011 JUNE AUGUST GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? HAZARDOUS Caged Tiger ACTIVITIES Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER SLIPS, LEAVES TRIPSTHE AND GATE FALLS OPEN Obstructions, trip and Gate operates automatically fall hazards on VL clearly marked Non-slip on all Gate has failure alarm walkways, working areas and ladders PERSONAL INJURY SLIPS, TRIPS Zoo: Tiger Escapes AND FALLS: LOSS OF CONTROL Capability Search of crew Plan planto deal with incident Dart Dart gun Gun used by by Zoo zookeeper Keeper Learning from incidents PERSONAL MAULS OR INJURY KILLS MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
16 COLLAPSED STOW
17 Containers should be in a good condition with doors closed and secure. An effective lashing system should be in place MON TUE WED THU FRI SAT SUN Engineers Toolbox talk sweatband fashion competition Containers in a poor condition, or with unstable stow, should not be accepted. Cargo like this can cause incidents and loss of cargo overboard, for which the ship may be liable AUGUST 2011 JULY SEPTEMBER GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? CONTAINER/ CAR/RO Caged Tiger RO CARGO Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER COLLAPSED LEAVES THE GATE STOW OPEN Gate Stowage operates position automatically procedures Gate has failure alarm Securing/lashings CARGO CONTAINER/ CAR/RO RO Zoo: Tiger Escapes COLLAPSED STOW: LOSS OR DAMAGE Emergency Search reporting/ Plan plan communication procedures Dart Dart gun Use Gun used of third by by Zoo zookeeper party Keeper assistance MAULS CONTAINER OR KILLS MEMBER CARGO OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
18 NAVIGATION UNDER PILOTAGE
19 MON TUE WED THU FRI SAT SUN DEPLETED AIR BOTTLES Excessive numbers of engine starts/stops during manoevering will deplete pressure in the main engine start bottles which can result in loss of control of the vessel at critical times, such as when docking, due to the engine failing to start Be nice to officers day SEPTEMBER 2011 AUGUST OCTOBER GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? SHIP/CREW Caged Tiger ACTIONS Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. NAVIGATION KEEPER LEAVES THE GATE UNDER OPEN PILOTAGE Gate Use operates of engine automatically avoid collision Gate has failure alarm Competency of pilot PILOTAGE: THIRD PARTY Zoo: Tiger Escapes PROPERTY DAMAGE Emergency Search reporting/ Plan plan communication procedures Dart Dart Record gun Gun used keeping/evidence by by Zoo zookeeper Keeper retention THIRD PARTY MAULS PROPERTY OR KILLS MEMBER OF THE DAMAGE PUBLIC MONETARY COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
20 TANKER - CONTAMINATION
21 MON TUE WED THU FRI SAT SUN TANK CLEANING Tanks should be thoroughly cleaned prior to loading. The photos above show a newly coated tank and one that is properly cleaned, although the coating is starting to break down Above, bad tank cleaning with vegetable oil in a skip and all over the deck Sweep fallen leaves from deck OCTOBER 2011 SEPTEMBER NOVEMBER GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board. Creating a bowtie diagram from the situation above there are many more barriers, can you find them? TANKERS (CRUDE/ PROD/CHEM/GAS) Caged Tiger CARGO Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER LEAVES THE CONTAMINATION GATE OPEN Tank and pipeline Gate operates automatically preparation/checks prior to loading Gate Cargo has segregation failure alarm procedures CARGO TANKER Zoo: Tiger Escapes LOSS OR DAMAGE Damage Search mitigation Plan plan procedures Dart Dart gun Gun Record used keeping/ by by Zoo zookeeper Keeper evidence retention LIQUID MAULS OR CARGO KILLS MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
22 LEARNING FROM INCIDENTS
23 Learning from incidents Are lessons learned from previous incidents Non conformity raised for incident Incident/Accident report correctly filled in Incident is raised at safety meetings and full crew meetings: -Discussion of what went wrong and how this can be avoided in future Incident is discussed and appraised at Company level: -Actions to avoid future incidents are discussed and taken, improving barriers Incident promulgated to full fleet to avoid duplication if possible Incident promulgated industry wide if appropriate to enhanced safety culture Full risk assessment undertaken to improve barriers/ controls in on board checklists Toolbox talks, job hazard awareness (JHA) systems and others as appropriate in all fleet vessels MON TUE WED THU FRI SAT SUN Wet deck skating competition NOVEMBER 2011 OCTOBER DECEMBER GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job can create better ownership of safety for all the work force and therefore reduce accidents on board. Sit down and plan the job! A toolbox talk takes only 5 minutes and is an essential tool in the management of risk at work. LIFEBOAT DRILL LAUNCHING Caged Tiger AND RECOVERY PERSONAL INJURY LIFEBOAT Zoo: Tiger Escapes TRAINING: TRAINING ACCIDENT Dart gun used by zookeeper Damage mitigation procedures Search Plan plan Alarm/Stop procedures Dart Dart gun Gun used by Zoo zookeeper Keeper Emergency drills/training Emergency Search equipment Plan plan adequacy/availability Dart Dart Emergency gun Gun used by by reporting/ Zoo zookeeper Keeper communication procedures Record Search keeping/evidence Plan plan retention Dart Capability gun Gun used of by crew by Zoo zookeeper to Keeper deal with incident Use Search of third Plan plan party assistance Dart Dart gun Gun used by Zoo zookeeper Keeper Learning from incidents PERSONAL MAULS OR KILLS INJURY MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
24 GALLEY WORKING
25 MON TUE WED THU FRI SAT SUN GALLEY ATTIRE Clean protective clothing should be worn at all times. Flip flops are not only bad hygiene, they offer no protection from scalds or from dropped objects and present a slip/trip hazard Sleep Sick bay Party More Party GALLEY HYGIENE It is important to use clean, colour coded cutting boards and utensils, that have been properly disinfected. Dirty boards, cloths and surfaces can spread germs and cause cross contamination DECEMBER 2011 GOOD RISK MANAGEMENT REDUCES ACCIDENTS ON BOARD Human error is the major cause of accidents on board, a simple risk assessment prior to any job, as shown here, can create better ownership of safety for all the work force and therefore reduce accidents on board NOVEMBER JANUARY 2012 Creating a bowtie diagram from the situation above there are many more barriers, can you find them? HEAT, SHARPS, OILS, Caged FOOD Tiger CONDITIONS Sit down and plan the job! A toolbox talk (pre-job planning meeting) takes only 5 minutes and is an essential tool in the management of risk at work. KEEPER GALLEY LEAVES THE ACTIVITIES GATE OPEN Housekeeping Gate operates automatically standards maintained in all areas Food Gate preparation has failure alarm and handling procedures PERSONAL INJURY GALLEY Zoo: Tiger Escapes WORKING: LOSS OF CONTROL Capability Search of crew Plan planto deal with incident Dart Dart gun Gun used by by Zoo zookeeper Keeper Learning from incidents PERSONAL MAULS OR INJURY KILLS MEMBER OF THE MONETARY PUBLIC COST C5 C3 UK P&I CLUB IS MANAGED BY THOMAS MILLER
26 UK P&I CLUB IS MANAGED BY THOMAS MILLER For further information please contact: Loss Prevention Department, Thomas Miller P&I Ltd Tel: Fax
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