HOW TO PREVENT ACCIDENTS HAPPENING ON SHIPS ?

By Reactive approach of maritime management

 Developed by fatal accidents

 Accidents revealed deficiencies in legislation, management and ships’ construction

 Safety has eventually improved

==

Near misses definition

 Near-miss is defined as the sequential happenings that haven’t resulted in loss and/or
injury but has the risk to do so. Loss can be a personal injury, environmental damage
and/or negative financial effect on the trade. Mentioned loss has been prevented by a
fortunate break in the chain of events (IMO MSC-MEPC.7/Circ.7, 2008)

 Proactive approach(use of near misses)

 The use of occurrences those might have resulted in accidents(near misses)

 The circumstances ending up in either an accident or a near-miss are most likely similar

 According ISM Code near misses should be considered as incidents regarding reporting
procedure

 Near misses reporting advantage

 Near-misses could deliver experiences valuable to the future safety strategy

 Reporting near-misses plays an important role in learning from mistakes, preventing

accidents and suffering from their serious consequences

 Reach a proactive way to handle future maritime safety.

Safety culture definition

==It is a culture in which there is considerable informed endeavour to reduce risks to the
individual, ships and the marine environment to a level that is as low as is reasonably
practicable (IMO MSC-MEPC.7/Circ.7, 2008)

==

Safety culture creation

Efforts to create a philosophy that implementation to regulation is not compliance to
bureaucracy but an effort to actual improvement of safety.

==

An ILO code of practice

Accident prevention on board ship at sea and in port
The International Labour Organization was founded in 1919 to promote social justice and,
thereby, to contribute to universal and lasting peace.

Its tripartite structure is unique among agencies affiliated to the United Nations

In accordance with the decision taken by the Governing Body of the ILO at its 254th Session
(November 1992), a Meeting of Experts was convened in Geneva from 28 September to 5
October 1993 to revise the ILO Code of Practice on Accident Prevention on Board Ship at Sea
and in Port.

The objective of this code is to provide practical guidance on safety and health in shipboard
work with a view to:

(a) preventing accidents, diseases and other harmful effects on the health of seafarers arising
from employment on board ship at sea and in port;

(b) ensuring that the responsibility for safety and health is understood and remains a priority
for all concerned with maritime transport, including governments, shipowners and seafarers;
and

(c) promoting consultation and cooperation among governments, as well as shipowners' and
seafarers' organizations in the improvement of safety and health on board ship.

1.1.2. The code also provides guidance in the implementation of the provisions of the
Prevention of Occupational Accidents to Seafarers Convention, 1970 (No. 134), and
Recommendation, 1970 (No. 142), as well as other applicable ILO Conventions and
Recommendations.

==

ISM
The ISM Code was adopted by the International Maritime Organization (IMO) by resolution
A.741(18).

The objectives of the ISM Code are to ensure safety at sea, prevention of human injury or loss
of life, and avoidance of damage to the environment, in particular, to the marine environment,
and to property.

The Code requires companies to establish safety objectives as described in section 1.2 of the
ISM Code.

In addition companies must develop, implement and maintain a Safety Management System
(SMS) which includes functional requirements as listed in section 1.4 of the ISM Code.

Applicability of the ISM Code

SOLAS, Chapter IX, and the ISM Code applies to ships, regardless of the date of construction, as
follows:

 Passenger ships, including passenger high-speed craft, not later than 1 July 1998
 Oil tankers, chemical tankers, gas carriers, bulk carriers and cargo high-speed craft of 500
gross tons or more, not later than 1 July 1998
 Other cargo ships and mobile offshore drilling units (MODUs) of 500 gross tons or more,
not later than 1 July 2002

Background to the International Safety Management (ISM) Code

The Code's origins can be traced back to the late 1980s, when concern was growing about poor
management standards in the shipping industry.

In 1989, IMO adopted Guidelines on management for the safe operation of ships and for pollution
prevention "to provide those responsible for the operation of ships with a framework for the proper
development, implementation and assessment of safety and pollution prevention management in
accordance with good practice."

These guidelines were revised in November 1991 and the ISM Code itself was adopted as a
recommendation in 1993.

However, after several years of practical experience, it was felt that the Code was so important that
it should be mandatory.

It was decided that the best way of achieving this would be through the International Convention
for the Safety of Life at Sea, 1974 (SOLAS).

This was done by means of amendments adopted on 24 May 1994, which added a new Chapter IX
to the Convention entitled Management for the safe operation of ships.

The Code itself is not actually included in the Convention, but is made mandatory by means of a
reference in Chapter IX.

== The Code requires a safety management system (SMS) to be established by "the

Company", which is defined as the ship owner or any person, such as the manager or
bareboat charterer, who has assumed responsibility for operating the ship.

This system should be designed to ensure compliance with all mandatory regulations and that
codes, guidelines and standards recommended by IMO and others are taken into account.

The SMS in turn should include a number of functional requirements:

 a safety and environmental protection policy; instructions and procedures to ensure safety
and environmental protection;
 defined levels of authority and lines of communication between and amongst shore and
shipboard personnel;
 procedures for reporting accidents, etc.;
 procedures for responding to emergencies;
 procedures for internal audits and management review.

The Company is then required to establish and implement a policy for achieving these objectives.
This includes providing the necessary resources and shore-based support. Every company is
 expected "to designate a person or persons ashore having direct access to the highest level of
management".

The Code then goes on to outline the responsibility and authority of the master of the ship. It states
that the SMS should make it clear that "the master has the overriding authority and the
responsibility to make decisions ..." The Code then deals with other seagoing personnel and
emphasizes the importance of training.

Companies are required to prepare plans and instructions for key shipboard operations and to
make preparations for dealing with any emergencies which might arise. The importance of
maintenance is stressed and companies are required to ensure that regular inspections are held and
corrective measures taken where necessary.

The procedures required by the Code should be documented and compiled in a Safety Management
Manual, a copy of which should be kept on board. Regular checks and audits should be held by the
company to ensure that the SMS is being complied with and the system itself should be reviewed
periodically to evaluate its efficiency.

==

RECENT ACCIDENT AND LESSONS LEARNED.

Incinerator safety devices bypassed and accident.

 The vessel was underway when the incinerator alarm sounded, indicating the
inside sluice gate was open. The incinerator was stopped and allowed to cool.
A few hours later, the 4th engineer went to the incinerator room to
investigate.

Standing on a small step, he opened the garbage loading door and also the
sluice gate.

(The incinerator feed system is such that when one door is open, the other
must be closed and vice versa. Two different safety devices near the feed door
ensure this operation; these must be overridden in order to look into the
incinerator sluice chamber.)

When the sluice gate was opened, he saw a piece of wood at the opposite end
of the garbage loading door. While checking, he accidentally dropped his
torch inside the incinerator door.

While trying to recover the torch, the automatic sluice began to close and
trapped his arm.

His arm firmly stuck, the 4th engineer tried to call for help but nobody heard
him.
After coffee, the 2nd engineer went to the incinerator room to see how the job
was progressing and investigate why the 4th engineer was not at coffee.

He found the 4th engineer trapped; he immediately released the victim and
brought him to the ship’s hospital.

Emergency notifications were initiated and treatment was given as per

medical advice.

The vessel deviated from its route but evacuation was delayed by foul weather
and darkness.

The next morning the vessel was brought alongside and the victim evacuated
by land.

In the hospital, no fracture was apparent but a total obstruction of all blood
vessels to the hand and forearm was confirmed.

Surgery was performed immediately but to no avail and amputation of the

forearm was unavoidable.

Lessons learned

-Never bypass the safety features of an installation and always follow the
procedures.

-The amount of waste fed at any one time should be in quantities that do not
tend to block the incinerator doors.

-Working alone in isolated areas has increased risks and should be the subject
of a risk analysis.

-Apparently, objects blocking the incinerator doors was a fairly regular

occurrence (once a month) on this ship.

It is possible that this ‘common occurrence’ encouraged complacency and

risky behaviour such as taking shortcuts and bypassing safety features on the
equipment.
Note:
The lessons learned from that incident were:

-Proper training and supervision are critical with operations such as

incineration.

-Incineration on this ship is best undertaken by two persons.

-Ship-specific Job Hazard Analysis should be done for incineration, as for all
vessel activities.

-Under normal conditions, safety devices such as micro switches should never
be ‘tricked’.

If junior officers are by-passing safety features such as micro-switches in the

course of their normal duties, it is highly probable that senior officers are
aware of this behaviour.

This would indicate a lack of safety leadership, undermining the safety

culture.

================

ACCIDENTS and REPORTING

WHY ACCIDENTS ?

While huge strides continue to be made in improving marine safety, human error remains the most
important factor in marine accidents.

And competitive pressures coupled with the increasing size of vessels mean that training and
quality of crew are becoming ever more important, experts say.

Marine safety is an issue that is always near the top of the agenda for the International Union of
Marine Insurance, according to its secretary general, Lars Lange.

Most casualties are the result either of equipment failure or human error or a combination of the
two, with human error the dominant factor.
A report last year by Allianz Global Corporate & Specialty, a unit of Munich-based Allianz
S.E., showed that while shipping safety has improved greatly over the past 100 years —
since the sinking of the Titanic — and the size of the world's commercial shipping fleet has
trebled in that time, there still are key challenges to marine safety. The main challenge,
according to the report, is human error, which accounts for more than 75% of marine
losses.

“The reason behind any given casualty is usually complex and hard to attribute to a single
cause — inevitably it is a mixture of a number of things,” .

While accidents are mostly due to mistakes, they rarely are caused by a single person and should be
viewed “in the context of the whole organization — both onboard and ashore.”

While the immediate cause of an accident may be the result of the actions of an individual, these
frequently “are the result of factors in the local work environment which are a consequence of
organizational factors,” he said.

Economic pressures may mean that some ship owners may have reduced their training budgets.

While many owners invest heavily — financially and in terms of time — in training of crews, some
owners that are under financial pressure may not.

Much training is carried out on simulators, and this may not properly teach officers how to, for
example, manoeuvre a ship in and out of a harbour.

This can lead to inexperienced officers operating without the required expertise, he said.

The quality of officers and crew employed by a ship owner is a key factor for marine underwriters
in assessing risk.

Language differences between international crew members can lead to misunderstandings and
result in mishaps and so good training is essential.

The retention of crew members is another important factor in safety and for underwriters of
marine risks. “Ship owners go the extra mile to keep their crew,” and retention rates of about 80%
to 90% are ideal.

Many ship owners have taken steps to retain crew members, for example, by offering rejoining
bonuses or installing satellite TVs and improving the conditions for crew.

A lack of proper maintenance can lead to technical faults that can cause or contribute to accidents.
Owners must ensure that time pressures do not lead them to reduce the amount of maintenance
carried out on vessels

According to marine safety experts, shipping companies seeking to improve safety should:
• Establish programs to train crew in electronic chart display and information systems.

• Increase focus on bridge resource management training and retraining, including realistic
scenarios.

• Share lessons learned from incidents at crew conferences and while onboard ship to identify and
discuss all factors that contributed to an incident, not just a single root cause.

• Establish a culture of organizational learning to share “near misses” and lessons from others.

• Marry the use of technology and human expertise.

• Ensure that crew are experienced in the type of vessel to which they are going to be deployed.

• Make sure you are confident about the risk assessment and management support you will receive
from your classification society and flag carrier.
==

Why to investigate accidents?

To establish what happened and why it happened so that the causal factors are fully understood
and action can be taken to:

• prevent such an accident happening again;

• ensure standards of safety and competence are maintained; and

• that reckless and irresponsible behaviour be avoided

==

Importance of the investigation and reporting to IMO

Why to investigate and submit reports to IMO?
1 To fulfil international responsibilities (UNCLOS, IMO instruments)

2 To be analysed in accordance with the terms of reference of the FSI Sub Committee

3 From the analyses carried out, each analyst submits a draft of any lessons to be learned for
presentation to seafarers.

4 The FSI also examines the analysis of investigation reports to determine if there are potential
safety issues in way of trends or recurring contributing factors.

5 To refer safety issues to relevant IMO Sub-Committee.

6 To draft safety recommendations, when appropriate.

===
Responsibilities of the Flag State :
• UNITED NATIONS CONVENTION ON THE LAW OF THE SEA (UNCLOS), Article 94,
Duties of the flag State, provides, in paragraph7;

Each State shall cause an inquiry to be held by or before a suitably qualified person or
persons into every marine casualty or incident of navigation on the high seas involving a
ship flying its flag and causing loss of life or serious injury to nationals of another State or
serious damage to ships or installations of another State or to the marine environment.

The flag State and the other State shall cooperate in the conduct of any inquiry held by
that other State into any such marine casualty or incident of navigation.

• International Convention for the Safety of Life at Sea (SOLAS), 1974, as amended,
Regulation I/21, Casualties, provides

(a) Each Administration undertakes to conduct an investigation of any casualty occurring

to any of its ships subject to the provisions of the present Convention when it judges that
such an investigation may assist in determining what changes in the present regulations
might be desirable.

(b) Each Contracting Government undertakes to supply the Organization with pertinent
information concerning the findings of such investigations. No reports or
recommendations of the Organization based upon such information shall disclose the
identity or nationality of the ships concerned or in any manner fix or imply responsibility
upon any ship or person.

International Convention for the Safety of Life at Sea (SOLAS), 1974, as amended,
Regulation XI-1/6,

Additional requirements for the investigation of marine casualties and incidents

(res.MSC.257(84)

provides:

22 .1 the provisions of part I and II of the Casualty Investigation Code (res.MSC.255(84))

shall be fully complied with; .

2 Part III should be taken into account to the greatest possible extent in order to achieve a
more uniform implementation of the Code

• International Convention for the Prevention of Pollution from Ships, MARPOL

• Article 8, Reports on incidents involving harmful substances, provides:

(1)A report of an incident shall be made without delay to the fullest extent possible in
accordance with the provisions of Protocol I to the present Convention.

• Article 12, Casualties to ships, provides:

 (1) Each Administration undertakes to conduct an investigation of any casualty occurring
to any of its ships subject to the provisions of the Regulations if such a casualty has
produced a major deleterious effect upon the marine environment

(2) Each Party to the Convention undertakes to supply the Organization with information
concerning the findings of such investigation

• International Convention on Load Lines, 1966, Article 23, Casualties, provides:

(1) Each Administration undertakes to conduct an investigation of any casualty occurring

to ships for which it is responsible and which are subject to the provisions of the present
Convention when it judges that such an investigation may assist in determining what
changes in the Convention might be desirable.

=============================lsg=================