4Q2012 Near Miss Report Summary 4Q2012
BP Oil Shipping Time Charter Fleet Near Miss Review Please share the attached Summary and this message of thanks with all your crews so that they can receive the feedback they deserve for taking time to submit the reports in the first place. We hope that this publication continues to be a prop that can be used by our partners during safety meetings, spare time reading, crew change tool box meetings and any other time you might think. The NM summation only includes NM considered to contain information deemed important enough to share with our time charter partners. The categories are only for grouping these together in an effort to look at trends. During the course of 2012 more than 512 near miss (NM) reports were submitted by our shipping and barging partners. This is no small feat, and thanks to you all five (5) of BP s Core Values can be demonstrated. BP Shipping thanks all the deck hands, tankermen, QMEDS, pilots, wheelmen, oilers, engineers, mates, masters and companies that had the courage to share their near misses with us. These reports have been reviewed on a monthly basis and a few have been selected so that they can be respectfully shared on a quarterly basis. It is with such excellent attitude that we can demonstrate a One Team culture towards elevating safety performance. Keep sending the near miss reports in, and we wish you all a safe and successful 2013. The BP Shipping (USA) R&M Assurance Team 2
of Change- Condition Mechanical Mechanical While disconnecting the arms one of the crewmembers was observed standing in a hazardous location while one of the arms was moving. The berth operator stopped moving the arm and the crewmember was told to move to a safe location. Crewmember was new to the job, was trying to be helpful, but did not understand the potential hazards. Improved training of new hires, ensure they fully review the Job Hazard Analysis before starting the task and continue to stress situational awareness. While making a deck round, found several foam stations with the valves left open and the caps off hydrants. Secured the valves and capped the hydrants. Unknown at the time, but the state of readiness of the firefighting system was changed, leaving it less effective in the event of an emergency. Discuss at safety meeting the need to keep the firefighting system in a state of readiness. NM submitted for lesson learned. During pre-arrival inspections and tests, inert gas was smelled in the vicinity of the two headers to be used. The reducers had just been installed on the two headers. The reducers were removed, their faces cleaned and reinstalled with new gaskets. Pitting from corrosion. Pressure test reducers after installation to ensure tightness, reface reducers and reconsider stowage location. After disconnecting a loading arm, the arm unexpectedly dropped onto the manifold drip pan. The control was temporarily erratic. The berth operator regained control of the arm and sowed it ashore without further incident. Unknown at the time. Vessel crew remained a safe distance from the loading arm until it was safely ashore. While making rounds in the engine room, the engineer noticed a puddle of liquid under the starboard generator. The liquid was found to be diesel fuel leaking from a hose off a filter housing. Brought port generator on line, secured starboard generator and replaced the hose. The hose had been chafing against an engine bracket. The engine had recently been overhauled in the shipyard period. Inspect for even the smallest details after work on equipment has been done, especially by outside contractors. 3
of Change- Human Error While conducting a routine deck inspection, a crew member found the forward dock fender was hung up on the barge rub rail. The rising tide and cargo discharge would have resulted in a seriously unsafe circumstance. Cargo discharge was secured and the bow lines were slacked to disengage the fender without incident. The dock was designed for larger vessels. Continued vigilance on mooring lines, dock fenders and conditions such as tides and currents. At completion of cargo operations a deck round was made. A drain valve from the cargo header to the drip pan was found open. Leaving the valve open could have led to a cargo release at the next load. The valve was closed and all valves in the system were checked to ensure they were closed. The valve was inadvertently left open after draining the header. Stress the importance of securing valves in the system after cargo operations. Create a postcargo checklist similar to the pre-cargo checklist. A crew member was observed putting a large piece of broken glass into a common-use trash can. This could have injured someone handling the trash bag. Safety intervention to correct the unsafe situation. The shard was repackaged and placed in a labelled container. Lack of awareness that an unsafe condition had been created. NM was submitted and the incident was discussed at the next safety meeting. During monthly test/inspection of the fixed foam system, low water flow was observed coming through the spray nozzles. A Y strainer was found to have debris restricting flow. The strainer was cleaned out and flow returned to normal. None noted. Amend monthly inspection to inspect the strainer. Consider installing a ball valve upstream of the strainer to facilitate inspection and cleaning. During monthly test/inspection of the fixed foam system, low water flow was observed coming through the spray nozzles. A flow regulator was found to have debris restricting flow. The regulator was disassembled, cleaned out and re-installed; flow returned to normal. None noted. Continue following the maintenance and inspection schedule, especially for lifesaving and fire fighting equipment. 4
Mechanical The step into the galley stores area and refrigeration flat was found loose. The step was properly secured. The step had been un-mounted to facilitate cleaning and not re-secured. NM was submitted and discussed. The lesson learned about leaving damaged tools or equipment creating an unsafe working condition was shared. During a shipyard period two lifting padeyes were installed- one on the port side of the vessel, the other on the starboard. A crew member intending to use one padeye noted that it had only been tack welded and was likely to fail if it was used for a lift. Alternative lifting arrangements were made, and the padeye is marked not to be used. Unfinished shipyard work. Crew member stopped the work and reported the unsafe condition. Cleaning up after a shipyard period a homemade hammer was discovered, consisting of a hammer head welded to a piece of pipe. The hammer was destroyed and disposed of. Unknown Be on the lookout for homemade tools and dispose of them. Cleaning up after a shipyard period parts were discovered on a horizontal frame in the upper engine room. There was no vertical face or rail to prevent these from falling and hitting someone. Parts were immediately removed. Parts were left during the job and not secured when the job was finished. Inspection was made for other hazards and crew members were reminded to eliminate hazards as soon as they are recognized. While transiting in a channel a sailboat was seen operating erratically. A deep draft vessel was informed of the sailboat and evasive maneuver was taken. Unknown Heightened awareness, making others aware of the situation. During maintenance on a compressor, a faulty air line check valve was found. The extra back pressure could have resulted in damage to the equipment and/or injury. The crew installed a new check valve Check valve was in service past its useful life. Crew to continue to be alert for signs of defects. 5
A ladder that had been condemned for use was tagged as out of service but not removed from the vessel for an extended period. This increased the risk of someone trying to use it and possibly getting injured The ladder was promptly removed at the first opportunity. None identified Near miss was submitted, discussed among the crew. While attempting to remove a watertight door, the hinge pins were found to be frozen in the hinges. It was decided to try heating the pins. Stop Work Authority was exercised until a hot work permit was obtained and the JSA was amended to include the change in scope of the task. Change in the scope of the task. Near miss was submitted, discussed among the crew. During a routine walk around the vessel there were several items identified that were cut or broken leaving exposed jagged edges. Another inspection focused on jagged or sharp protrusions identified the hazards and the items were discarded, replaced or otherwise corrected. Deteriorated fittings were neglected. Photographs were taken to review with returning crew members. Near miss was submitted, discussed among the crew. Dock PIC came on board to disconnect the loading arm and started to close the vessel's header valve without consulting the tankerman. The tankerman explained that draining was not complete. Unclear lines of responsibility. Pretransfer conference now details everyone's responsibilities before the start and after the finish of cargo transfer. A crew member was working at a height less than 6' from the deck, but over the rail protecting a fall to the next lower deck. A Working at Heights permit was identified in the JSA but not completed. Work was stopped until the permit was completed and the proper equipment was used. Poor awareness, failure to follow JSA. Near miss was submitted, discussed among the crew. A crew member was working with a chipping gun with multiple air leaks. Work was stopped until the leaks were secured and the job resumed. Poor awareness, failure to follow JSA. Worn fittings were replaced and the JSA was reviewed that called for tool inspection prior to and after use. 6
Distraction Distraction A barge sailed with a maximum flood current on the stern without an assist tug, using the bow thruster. The tow was difficult to maneuver. None Orders to the next berth were sent on short notice. The Captain did not want to lose his spot at the next berth. Will assess the situation for risk each time and raise concerns in the future. A crew member noticed an open and unattended tank opening. The opening was attended until the replacement could be fitted. The plate had been removed and set aside while the replacement plate was being retrieved from storage. Discussed with the crew a better course of action- leave the plate on until the replacement was brought to the work site. While backing empty barges off the bank the wheel wash capsized the tug s skiff. The skiff was recovered and put in its proper place. The skiff had not been put back on deck before getting underway. The incident was discussed with the crew and used as a safety meeting topic. A tankerman was crossing from a barge to a tug alongside. He slipped on the handrail on top of the bulwark and fell between the boat and the barge, landing on the fender. Crewman was taken for medical evaluation and found fit for duty. None reported. None reported. A Mate was loading and deballasting concurrently and did not notice the mooring wires were excessively tight until the barge began to list. Tension was released on the mooring wires. Too many concurrent tasks for the individual. None reported. Assistant Engineer was transferring fuel to the day tank. A vendor servicing equipment asked for assistance and the engineer left the fueling station to help. He was alerted by hi-level alarm. The transfer was stopped without overfilling the tank. Distraction New procedures instituted that you cannot leave the designated fueling station. 7
A crewman was crossing from a tug to a barge alongside. The barge was being rigged from push to tow. He missed a step and fell. None Rushing and overreaching. Crew met later to discuss the incident and were reminded not to rush. A crewman was assisting the barge PIC and thought he heard the dock office say they were blocked in ashore. He started closing the barge header valve. The PIC told him to leave it open. Rushing and overreaching. Crewman was instructed to only make changes to the cargo system at the direction of the PIC. 8