CHIRP Maritime recently published an editorial comment in The Maritime Executive titled ‘If Nobody Entered Enclosed Spaces…’. The article narrates the possible reasons for enclosed space fatalities and briefs about the analysis and prevention of such accidents.
Situational Awareness
- Is everybody involved in the operation fully aware of all potential hazards involved when entering an enclosed space, whether it is an obvious confined space or not?
- Has there been a team briefing as to the potential for incident and the possible repercussions of neglect?
- Are there procedures in place to counter each perceived or potential hazard that might occur?
Alerting
- Does everybody involved in the operation know how to raise an alarm about a situation, or more importantly how to raise a concern about a situation before it warrants raising an alarm?
- Equally important, are you confident enough to raise any concerns without any fear of repercussion?
- If you have a query or are not sure about any particular part of the proposed operation, then speak up.
Communication
- Are people involved, especially those in supervisory roles, truly communicating information to others so that everybody involved understands the task and potential hazards involved?
- If you enter an enclosed space can you effectively communicate with those outside at all times – or are there “blind” spots. If so, what can you do to mitigate this risk?
Complacency
- The expression ‘familiarity breeds contempt’ can be re-written as ‘routine breeds complacency’.
- Are you sure that all aspects of the intended operation have been covered? Just because you have done it many times before does not mean that the answer is “Yes!”
Culture
- There are some cultures that are reluctant to question or even interact with figures in authority or from other cultures. Conversely there are some cultures or individuals who are reluctant to accept ‘interference’ from others.
- This is often referred to as “cockpit culture” and refers to historical incidents within the aviation industry that resulted in the total loss of aircraft and crew because the assisting flight crew did not challenge the Captain’s fatal decision even when they knew it to be wrong.
- Whilst it may sound incredible, this social psychology phenomenon is well documented. Does your system on board take this into account and actively challenge it?
Local Practices
- People in supervisory positions need to be aware of local practices. Just because something is local practice doesn’t in itself make it undesirable.
- Is this a case of “We’ve always done it like this?” It can be a difficult cycle to break but is the cause of many incidents and thus should be thoroughly addressed.
Team Work
Ensure all team members are fully conversant with the task and any potential hazards, especially when the team involves multi-national personnel or when individual team members have been replaced. NEVER ASSUME. As investigators say, “To ASSUME makes an ASS out of U and ME!”
Capability
- Are the personnel assigned to specific roles in the operation fully conversant with their duties and responsibilities and truly capable and competent to carry them out safely? If they were, we would not be having the tragic recurrence of incidents.
- Capability is not simply competence – other factors such as being physically able to do the required task need to be considered – this might apply, for example, to a case of tank entry in the Persian Gulf in summer.
- The truth is, with reduced crew manning these days, the master has to rely on the personnel available and may face corporate pressure or bullying by his managers, but such pressures must be resisted.
Pressure
Is there realistically enough time and sufficient personnel to carry out the operation? Don’t allow other factors to interfere with a safe operation. This includes peer pressure to “get the job done.”
Distractions
- Ensure personnel involved with enclosed or confined space work are not distracted – other personnel should be aware of the ongoing operation and instructed not to interfere.
- Highlight to those involved the hazards of allowing themselves to be distracted. Distractions can also arise from work overload or personal issues, and all must be considered to ensure that a task is undertaken safely.
Fatigue
- Be aware of the debilitating effects of high humidity, high temperatures and high noise levels which might be encountered within an enclosed or confined space.
- Even wearing PPE (dust or respirator masks) can be tiring. Ensure personnel have adequate breaks, refreshment and rest periods.
- Ventilation is all important, and there must be no areas where there might be a build up of noxious gases, or a lack of oxygen – this should be assessed at the design stage of a compartment, but continuing incidents suggest that designs are not always perfect. This is why all areas of a compartment must be tested?
Fit for Duty
- Are the people assigned to the task of confined space entry physically and mentally fit for the job in hand?
- A person may be fit for their ‘routine’ duties but are they equally fit for the additional, arduous nature of confined space entry?
- Is it physically possible for a human to undertake the required task under the prevailing conditions?
Other considerations
- Every confined and enclosed space is different. They come in all shapes and sizes from massive cargo holds or tanks through assorted void spaces to incredibly confined double bottom tanks, single frame width cofferdams and bulbous bow spaces.
- Some spaces may not even be immediately identified as being dangerous, such as chain lockers or deck houses containing ballast water treatment plant.
- Whilst the two basic hazards of oxygen deficiency and toxic atmospheres are potentially present in all confined spaces, many other hazards may be space-specific such as access and egress points, ventilation and ventilation blind pockets, communications and ambient background noise.
- Where applicable, a compartment should be fully protected with equipment lock-out, to isolate electric circuits or to prevent the ingress of gases / liquids.
- On a VLCC, access through a tank lid at main deck level is quite easy but a slip from the ladder could lead to a fatal fall. However, rescue from the tank bottom can be relatively straight forward if the vessel is equipped with the right equipment and the crew has been competently drilled.
- By contrast, access to some double bottom spaces can be a nightmare, with the access points too cramped, or lightening holes too small to facilitate passage whilst wearing radios; breathing apparatus, etc.
- In the event of an emergency, a rescue can be virtually impossible within a short time period. Even rapidly exiting a space can be almost impossible if the seafarer is a long way into the space.
- A well thought out risk assessment should address all the above points, and systems or procedures should be in place to reduce the risk to acceptable levels. If this cannot be done, then the obvious answer is “Do not enter!”.
Solutions or more problems?
CHIRP Maritime suggests a potential solution is to reduce the risk of an incident by reducing the number of human entries into confined spaces:
It is common sense that if the number of interventions between humans and confined spaces are reduced, the number of potential accidents are equally reduced and statistically the number of fatalities must go down.
This might require a reassessment by legislators, classification societies, insurers and ship owners with regard to the frequency of inspection. However, it is not beyond the realms of possibility bearing in mind the realistic prospect of autonomous vessels operating in the near future.
Utilise specialists:
Other major jobs on board frequently involve teams of shore side contractors or riding crews, so why not apply the same solution to entry into confined spaces?
Confined space work is not complicated, but the work is out of the ordinary and can be labour intensive, so why not utilise specialist teams?
They can be third party or an in-house squad, arriving onboard with all the necessary equipment suitably calibrated and certified for the duration of a port call, maintenance period, short voyage or even an international passage.
Technology exists today whereby inspections can be conducted by robotic means or by drones, and this would completely do away with human intervention into compartments.
If Amazon can deliver products to your doorstep via a drone, then the maritime sector could easily utilise the same sort of technology to conduct inspections of enclosed spaces and reduce or eliminate the number of incidents in this area.
We simply have to get the job done!:
For generations, seafarers have had a culture that the job must get done. In sailing ships, if a vessel encountered a sudden squall, the sails had to be trimmed or shortened to avoid the risk of being dismasted.
If cargo broke adrift, it had to be secured or it might stave in the ships side with dire consequences. Seafarers’ tenacity, ingenuity and determination in urgent or emergency situations is legendary.
Nowadays, whilst there are still genuine emergency situations where those same traits of tenacity, ingenuity and determination can prevent an emergency becoming a disaster, there is frequently a work ethic of just getting on with it, even if the safety of the vessel is not at risk.
Whilst this is commendable, it can have consequences if there is an incident and the subsequent inquiry criticises the people involved.
Suddenly the strong work ethic translates in to a criminal violation of hours of rest, a circumventing of company procedures, or wilful neglect.
Regardless of any commercial considerations and pressures, the wilful neglect by the ship’s crew will be highlighted by the shipowner/manager seeking to limit liability.
Whilst recognising that vessels today are operating in an intensely competitive market, if the resultant commercial pressures are contributing to the continuing loss of life in confined space accidents then it must be time to pause and radically reassess the situation.
Shipboard SMS procedures often call for either three of four separate signatures on a confined space entry permit (e.g. performing authority, area authority / supervisor, gas tester, issuing authority).
It is believed that multiple signatories will perform checks and balances but each of those three or four individuals have their own workload in their own workplace and it is unlikely they will all be in the same location at the same time.
So, the person tasked with completing a permit is often seen scurrying about the vessel, permit pad in hand, seeking various signatures to endorse or authorise the permit. In small crew operations, who is there to carry out the checks and balances?
It could be argued that a single person dedicated to the task, trained and competent in the required disciplines could be a more conscientious and safer option than those three or four busy distracted individuals currently required to open a ‘Confined Space Entry Permit’.
This would be a commendable possibility. However, we know that the additional delays in implementing such a thorough procedure would most likely result in pressure from senior management to circumvent the proper process.
Logistical Support:
Most often a vessel’s planned maintenance programme is originated and controlled by the owners or vessel managers ashore. These people have a duty of care to ensure that all of the necessary and required equipment is supplied to the vessel to support the marine crew in completing the assigned tasks.
A simple example of this would be for the office to dispatch freshly calibrated gas detectors to their vessels as part of an exchange programme, in advance of the expiry of any current onboard units.
How often do ships accept that a gas detector received onboard only requires an annual third-party calibration? If the unit has been sitting in the agent’s car window in extreme heat for a prolonged period, it could be deficient before it even gets on board.
Onboard Supervision:
Some tragedies in enclosed spaces occur when vessels are in port and involve personnel who are not a part of the vessels complement – contractors for instance.
Port calls today are a nightmare of frantic activity, set against the time constraints of charterers requirements, daylight operations, tidal restrictions, pilot availability and many other factors. Vessels are inundated with people all requiring attention, induction and supervision by ships staff.
They may all know their own particular jobs and they may have been aboard the vessel before, but they may not be aware of the current situation on board unless properly advised by ships staff.
This requires positive management and supervision by vessel personnel which may not be easy when some or all of the above groups consider they don’t need or want supervision.
Nevertheless, the vessel’s ISM procedures should cover all of the above. Whilst the responsibility for carrying out these procedures effectively lies with the vessel, ensuring that it is possible to do so is entirely the responsibility of company management.
The Way Forward?
- Remove the need for tank entry. Extend inspection interval and align inspection interval with DD or in-port maintenance period. Revisit planned maintenance programmes and schedules.
- Design out ventilation dead spots within confined spaces, build in permanent forced ventilation. Utilise remote technology (drones, robotics, endoscopic inspection).
- Ensure checklists, permits and training regimes are applicable and fit for purpose. Ensure manpower demands are realistic.
- Ensure sufficient, suitable and viable equipment is available onboard and personnel are trained in its use.
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Source: CHIRP Maritime
