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1 IASS: Safety and Security for Passenger Ships and Offshore Alexandria 19-20 October 2009 Risk management at Sea/Offshore RISK Identification/Evaluation/Mitigation.

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Presentation on theme: "1 IASS: Safety and Security for Passenger Ships and Offshore Alexandria 19-20 October 2009 Risk management at Sea/Offshore RISK Identification/Evaluation/Mitigation."— Presentation transcript:

1 1 IASS: Safety and Security for Passenger Ships and Offshore Alexandria October 2009 Risk management at Sea/Offshore RISK Identification/Evaluation/Mitigation Case: The capsizing of AH tug Bourbon Dolphin west 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

2 2 Offshore Anchor Handling tugs F The Norwegian AH-tug Bourbon Dolphins capsizing, April 2009: F The Accident Investigation Committe concluded: F Defects in Risk Assessment for the operational hazards F Defects in the necesary safeguarding of relevant risks F The Risk Assessment should include all external hazards F as tandem operation by command from the rig’s towmaster F 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”

3 3 Offshore Supply and Anchor Handling Internationall Rules and Regulations: F The ISM Code F EU Standards for Safety and Health F Oil Companys guidelines (NWEA, etc), F Relevant National Regulations for S&H F Private standards as ISO 9001, ISO 14001, HS 18001, IK-HMS, etc.

4 4 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….”

5 5 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.

6 6 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/handling 5. Prepare for emergency situations 6. Procedures for internal audits & man. Control *) Including Policy for Risk Assessment

7 7 The Safety Culture (The Human Factor) We cannot imagine Safety and Health to be achieved by means of - PROCEDURES - INSTRUCTIONS without the proper qualification of personnel ashore and onboard, and: An adequate COMPANY STANDARD

8 8 The loss causation model

9 9 The 6 basic causes of ACCIDENTS 1. We think we deal with “facts”, but the “facts” often turns out to be false 2. 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”

10 10 The 6 most common HUMAN ERRORS: 1. Change of working condition or organisation 2. 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.)

11 11 The 7 job demands : 1. Meaningful job content 2. Need for variation 3. Need for learning 4. Need to make own decisions 5. Need for support and recognition 6. Feeling the job is socially accepted 7. Need for future prospects VSP twice a year - Min. 85 of 100 p. acceptable

12 12 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 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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14 14 Risk Assessment 1. 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 plan 5. Monitor and review

15 15 Risiko Reduksjon (The “4 T procedure”) Terminate the Risk (by replacement) 2. Treat the Risk (Change, modify) 3. Tolerate (Training/instruction/PPE) 4. Transfer (specialists/insurance/etc.)


17 17 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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19 19 Writing Procedures and Instructions F WHAT to do F WHO shall do it F WHEN shall it be done F WHERE shall it be done F HOW shall it be done F WHY shall it be done

20 20 Accident Investigation 1. Alle accidents have an immediate cause Someting failed, or an error was done 2. We must find the basic or core cause: Find the underlaying causes behind There are to categories of basic causes: A. Workplace condition B. Unsafe act of persons (Substandard act)

21 21 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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23 23 Quality training F Define or set the qualification requirement.... F How do the candidate meet? Find the gap? F Evaluate the gap and set up a plan for the training F Execute the training F Verifiy that the training have been effective F Verify that the candidate now meets the required qualifications.

24 24 CASE: Bourbon Dolphine The capsizing of the Norwegian Anchor Handling vessel ”Bourbon Dolphin”, during an Anchor Handling operation, west of Shetland, the 12. April lives lost.

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26 26 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

27 27 Anchor Handling Tug Problems In general, confusion about: 1. Lack of specific requirements for AH vessels 2. No international standard for Bullard Pull rating (Power balance do not include use of thrusters)” 3. Confusion about the winch ”Emergency Release 4. 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)

28 28 CASE: Bourbon Dolphin F 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: F Master Mariner Ian Clark, MSc, MNI (UK) F AH Captain Michael Hancock, MNI (UK) F Arne Sagen, Skagerrak Foundation, CNI

29 29 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

30 30 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

31 31 Bourbon Dolphin The 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”

32 32 Bourbon Dolphin: Learning lessons  ========O VESSEL \ TOWLINE \ 1.Never operate the AHV against the towline 2.If you do, do not use the thrusters to right, as the vessel may ”roll over” the vessel 3.Always operate the AHV with ahead trim

33 33 AH Vessels: Learning lesson 1.Stability Compartments 2.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

34 34 Modern Anchor Handling operation by programmed joystik NOTE: 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

35 35 Bourbon Dolphin: Learning lesson F STORING OF LIFERAFTS ON VERTICAL PLATFORM F _ UU___UU__ F I I F I _______ I F Standard fitting of liferaft cannister does F NOT release and deploy the liferafts by capsizing of the vessel ! (BD. I of 6) F

36 36 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.

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