Page 48 - CHIRP Annual Digest 2017

CHIRP Maritime

Article. 38 • No contributory causes of the error have been identified.
Fatigue was determined not to be factor.
Unmooring
Conclusions
OUTLINE: Whilst unmooring, the forward breast lines were • A review of the unmooring Job Hazard Analysis shows that
lowered by ships staff for release at the hook by the shore there is no direct reference to the need to communicate
linesmen. The officer in charge (OIC), assuming that the with shore staff to prevent this kind of incident. (Procedural
ropes had been released, gave the signal to the winchman improvement indicated).
to heave the ropes home. The winch operator commenced • The OIC had become involved in the releasing/retrieval
heaving. The OIC realized, simultaneously with advice of the mooring ropes and had momentarily assisted
relayed via the pilot and master, that one of the mooring the crew instead of overseeing the operation. (Lack of
ropes had not released. He signalled to the winch operator situation awareness).
to stop heaving, and to slacken the rope. The rope was • The lines of communication, for handling the breast lines,
then released by the linesmen and the unmooring opera- were insufficient as the OIC had not received a signal
tions continued. The pilot issued an incident report which from the linesmen ashore to verify that all was clear and
was followed up by the company. the mooring rope tails had been released from the hooks.
Additionally, this had not been acknowledged, and the OIC
Extracts from the Company Report: was not in a position to determine that shore linesmen
The company conducted a thorough investigation and analy- were in a position of safety away from the hooks. (Lack
sis of the incident, focussed upon human factors rather than of proper communication and improper position for the
blame. The salient points are as follows; operation).
• Mooring operations are covered by company’s Safety • A human behavioural issue was identified in the
Management System, including work control manuals unintentional risk taken by using time elapsed to infer
with specific reference to mooring. Procedures refer to critical information related to mooring operation.
appropriate industry publications, cover familiarization/ (Performance of a practice without risk appreciation).
training, job hazard analysis and proper operation/ • Finally, the fact that the winch was operated at high speed
maintenance of equipment. at the initial stage of heaving up implies inadequate
• The mooring team consisted of the OIC and four supervision. (Improper operation of equipment and lack
ratings. All personnel were experienced, considered fully of proper supervision).
competent for the mooring operation, and had completed
familiarization training prior to taking up any mooring Actions Taken
duties. They were familiar with the terminal, and the • The near miss analysis to be discussed with the terminal
communication practices between the linesmen and the operator to improve existing mooring practices.
mooring stations. • Just Culture process was applied with regard to the OIC,
• Prior to departure a tool box talk was given to all mooring and will include a training session.
party members and reported to the bridge. Similarly, the • A Fleet Circular issued, sharing the lessons learnt and
unmooring plan was agreed between master and pilot, requesting a mooring operation evaluation review to be
then communicated to all involved. discussed on board and shared across the fleet. The
• Communications were supervised by the bridge. Standard review to include a mooring operation hazard analysis
practice is that the OIC communicates directly with the to ensure the lessons learnt from this near miss are
shore linesmen and vice versa using visual signals. There incorporated, for use in future toolbox talks.
is no bridge intervention unless further clarification or • The lessons learned are to be included in Fleet Training
guidance is required. Officer material for on-board training.
• The linesmen unhook the lines once slacked by the
vessel. The OIC and the winch operator stand close to CHIRP Comment
each other, so that effective verbal communication can The Maritime Advisory Board emphasised that the person in
be maintained. During critical verification times, the OIC charge should not get involved in handling ropes and should
stands in a location which ensures that both the shore always maintain a full oversight of the operation. The com-
and ship’s teams can be seen. Following confirmation pany’s effort to investigate the human factors is refreshing
of release from the hooks, (by visual signal, which is – it is only by doing this that root causes will be properly
acknowledged), the vessel heaves up the lines using the addressed, as opposed to simply saying “Did not comply
winches, initially at slow speed. with the SMS!”.
• This was effectively implemented whilst releasing the
headlines. With the breast lines however, and at the Useful references – OCIMF Effective mooring, and the Nauti-
critical point of release, the OIC was not standing at the cal Institute Mooring and Anchoring Ships Volumes 1&2.
proper location, and was not able to verify that all lines
were released. Instead an assumption was made that the The above article was published in MFB49
lines had been released, based upon the elapsed time
from the last visual contact with the linesman. Although
unintentional, this was a violation of standard practice.
A further error was that the winch was operated at high
speed, in contravention of standard practice. It was not
clear why the winch operator acted that way.

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