The Best Laid Plans for Safety
Are Only as Good as Their Implementation!
January 1, 2017
January 3, 2017 - Safety Alert 1-17
Recently, while a bulk carrier was at anchor off the coast of Texas, a crewmember that could not swim was put over the rail in a Bosun's Chair to paint the vessel's mid-ship draft marks and load lines. Unfortunately, when his shipmates on deck commenced to haul him up, the Bosun's Chair line parted and he fell into the water. He survived the fall and attempted to swim towards a life ring that had been thrown to him, but he ultimately submerged and was lost. Other crewmembers attempted to launch a rescue craft, but it failed to operate.
Putting a crewmember over the rail to paint while a vessel is at anchor is a typical shipboard operation, and this instance is a classic example of where following SMS procedures could have prevented a death or injury.
Investigators found that the Captain and Chief Mate had met and developed a suitable work plan. This information was later communicated from the Chief Mate to the crewmembers involved. The plan had several important elements, including inspecting the Bosun's Chair and manila rope rigging and requiring
that the crewmember going over the rail wear a personal floatation device (PFD) and use a safety harness and lifeline; however, the plan was not implemented. Crewmembers failed to adequately check the strength of the Bosun's Chair line, instead simply pulling on it. Also, the deceased crewmember was not wearing a PFD, and, even though he wore a safety harness along with a lifeline, the lifeline went untended and was not tied off to the vessel. The vessel's Bosun was not present, and it remains unknown as to who was supervising the operation. Finally, months before this tragedy, the Chief Mate had placed a requisition request for new manila line and for PFD work vests that were designed to be worn with the vessel's safety
harness; however, the request went unfilled.
As a result of this casualty, the Coast Guard strongly reminds vessel owners and/or operators and all personnel onboard vessels everywhere to do the following:
Properly use safety equipment.
Ensure adequate supervision of work teams.
Develop workplace mindsets that properly develop and execute plans, including those for worst case scenarios.
Implement barriers to prevent such scenarios.
Fully implement and adhere to Safety Management System requirements.
This safety alert is provided for informational purposes only and does not relieve any domestic or international safety, operational, or material requirements. Developed by the Investigations Division of the Coast Guard Marine Safety Unit Port Arthur and the Office of Investigations and Casualty Analysis. Questions or comments may be sent to HQS-PF-fldr-CG-INV@uscg.mil.