Assumption Kills

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JK
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Assumption Kills

Post by JK »

So why did this guy die?
was he in a hurry? Lazy?
Took a chance?
Or just careless?


Ship death sailor 'needed permit'
A crewman who suffocated in a cruise ship's ballast tank did not have the necessary hazard permit, a report says.

Filipino Joselito Zordilla, 43, died testing water on the Saga Rose as it docked at Southampton on 11 June 2008.

A Marine Accident Investigation Branch report said he was told to do the tests on the basis the ballast tank was full, and its water accessible from outside.

But the tank was empty and he entered it despite being aware of the risks of low oxygen and not having a permit.

Paul Green, from the over-50s holiday company Saga which runs the vessel, told BBC News that the death of Mr Zordilla, a second boatswain, was "a tragic accident".


The report said that because of the assumption that the tank was full of water, "a permit to work was not deemed to be necessary".
"However, the tank contained only a small amount of water and the second boatswain entered it despite being aware of, and practised in, the vessel's procedures for entering enclosed spaces.

"The atmosphere inside the tank contained insufficient oxygen to sustain human life due to the corrosion of the tank's steel structure."

The Marine Accident Investigation Branch (MAIB) said Mr Zordilla's was the sixth death in an enclosed space it had investigated since September 2007.

'Proper procedures'

In view of this, the MAIB issued a safety bulletin in July 2008 setting out recommendations to regulators and the shipping industry "aimed at improving the identification of potentially dangerous spaces".

The Saga Rose, which is being replaced later this year, began its final world cruise with the company on Monday night.

Mr Green added that the MAIB report was "very thorough" and that Saga was "happy for them to take the lead".

He said crew members had been reminded of the proper procedures on board Saga's fleet of cruise ships.

"It was a tragic accident, which the MAIB accept," he said.

"As ever, the MAIB have been comprehensive and thorough."


Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/u ... 812673.stm

Published: 2009/01/06 10:07:37 GMT
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Sébastien
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Re: Assumption Kills

Post by Sébastien »

The simplest and fastest way to make a ballast tank safe to enter is to fill it with water to push out the stale air and empty it again so that fresh air enters the tank. He mistakenly thought this procedure had been employed since he was told the tank was full. He obviously missed a step, because the above procedure is to be done to expedite the air analysis, not replace it.
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Madzng
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Re: Assumption Kills

Post by Madzng »

http://www.maib.gov.uk/cms_resources/Saga-Rose.pdf

Above is the direct link to the MAIB Saga Rose report, unfortunately the BBC report does not go into enough detail.

Reading the MAIB report makes me question just how competent the officers of the Saga Rose were.

There was conflicting evidence regarding the tank contents.
The tanks could not be sounded because their sounding pipes were blocked.
The tank had probably been empty since it was last inspected in April 2005.
The crewmember concerned was asked to taste the water to see if it was salt or fresh.

Everyone is accountable for their own safety, but I can't help but feel that in this case others were also responsible.

There were too many assumptions made, not only by the victim but also by the officers directing him.

No matter how much education and safety videos are watched a lot of the older crew will still do what is asked of them, without question or thought. Simply because they believe in the person or his rank. It still takes a very brave individual to refuse a request or order from a supposedly competent sometimes very senior officer.

Don't ever under estimate the influence respect or rank can have on the requests that you make.

Does the permit to work system stop people from thinking about what job they are doing and concentrate on ticking boxes?

I have seen people training cadets in this method, and I am sure that some of them would not be capable of doing the job safely, without the tick boxes.

Safety should come from a proper education an understanding of the job, and what could go wrong. Not from a paper trail.
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JK
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Re: Assumption Kills

Post by JK »

I was just going to post the link as well. There is no excure for accidents like this other then complacency!
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Re: Assumption Kills

Post by offshoresnipe »

I have had my confined space /competent shipyard certificate for 7 years and take a 8 hour refresher class each year. It blows me away what I see done all the time. Just 3 weeks ago my 1st eng. wanted me to enter a tank he had sniffed, I told him no, he had never been to any school or had training on useing the meter. Just watching him fumble around with the meter does not make one feel very good. Needless to say that just pissed him off to no end. I have told the oilers and wipers to watch themselfs when diving tanks, just tell them you want more ventilation. It seems like durning the JSA meeting everone acts like they know what they are doing and will fill out the paper work so it all looks good. Get to opening up the tank or void and all sense seems to go away. My 1st likes to act like he knows what he is doing, instead of just saying never done this. I have seen guys pull the tank lid off and as soon as it hits the deck in goes their head, not sure what they are looking for. We all do dumb things, but I think the trick here is to wade in very slow, and maybe take time to think about what you are getting ready to do. Getting my confined space cert. has been one of the best things I ever did!
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Re: Assumption Kills

Post by conrod »

I dont know the vessel in question, and quite honestly it does not matter.

I was pretty amazed to read this story the other week. In the days of ISM (SMS), and the use of Permits to Work, pretty much compulsory now, I am still gob smacked to see mornons pull these stunts.

In my last Company, we had been operating a PTW system for at least 10 years. For tank entry 2 people onboard the vessel were usually appointed to test atmosphere prior to issue of the permit. They were right up to speed on the kit to be used, and once tested, routinely checked during operations. Before the permit was issued the Master had to sign it.

A copy ofthe PTW is posted at the tank entry, and it was valid for 12 hours. After that a new one issued.....with all the appropriate tests done and signatures obtained.

Sure you like to take short cuts sometimes, but its pretty difficult as a Senior Officer to tell someone to do something like this, and maintain any sort of respect. How can you get Jnr Officers and Crew to follow the " Code " if you cant do it yourself.................I have lots more to say on these type of topics...........but best not put into print on here, Martin might have to pull it.
Last edited by conrod on Sat Jan 10, 2009 1:43 pm, edited 1 time in total.
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JK
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Re: Assumption Kills

Post by JK »

You mean to say Conrad, you don't taste to see if the water is fresh or salt :wink:
(or in the case of a very funny story from the old steamer I was on, p water from a leaking sewage line )
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Re: Assumption Kills

Post by conrod »

Well you could say ..........drinking water is dangerous to your health, and we should all stick to can / bottle beverages !!
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Re: Assumption Kills

Post by The Dieselduck »

I have not had the chance to read the full report, but it is pretty obvious to me from JK's post, that there is allot more to the story than a simple mistake. I believe most crew know (should know) of the dangers of an enclosed tank, but just choosing to ignore procedures seems to have a regular and expensive cost.

Ironically, I was just asked by Worksafe BC, our local government workers compensation board, to take off safety related documents they published from my machinery page, one of them was regarding safety in enclose spaces. They say they want to make sure that people get the most accurate information by going to their website. Seems to me that getting the word out, proven over and over, ought to be a number one priority of the government, which ever.
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conrod
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Re: Assumption Kills

Post by conrod »

Well in reality Martin, you should not really have PTW forms on your web site. If they are marine related, then they should be developed by the individual company as per their SMS. If they are not marine related, then..........but you are right in what you say about awareness.
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Re: Assumption Kills

Post by The Dieselduck »

The one pamphlet I had on there was a general approach guide, and was quite general in nature, but well presented and certainly relevant to the marine industry. Of course every company should have there own guidelines, but there are certain unalienable truth about enclosed spaces, and ultimately the more you know the better off you are.
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offshoresnipe
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Re: Assumption Kills

Post by offshoresnipe »

Seems like the more information that is out, the better we all are.
I have found that many of the less experinced engine room crew members that I sail with have never had any information given to them, on confined space.
They are just following orders, sure that what they are being told is right. (As the 1st tells them he is behind them all the way!)
I think education is the key, and giving a crap about your job, the vessel, crew, etc.
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conrod
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Re: Assumption Kills

Post by conrod »

Well may be it's that I live in the dark ages then..........I assumed - obviously incorrectly - that PTW were a standard documents on all ships, covering working aloft, hot work, enclosed space entry........and several others, and that they were part of a SMS.

Boy have I had a sheltered life offshore for the last 26 years !! Good job I decided to come ashore.
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JK
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Re: Assumption Kills

Post by JK »

Inquest is on, the latest from BBC...dumbed down for the unwashed masses, obviously.

http://news.bbc.co.uk/2/hi/uk_news/engl ... 034947.stm

Dead sailor ship's 'pipe blocked'

A pipe used to indicate water levels was blocked when a crew member suffocated inside a ship's ballast tank in Southampton, an inquest has heard.

Filipino Joselito Zordilla, 43, died testing water on the Saga Rose as it was berthed in the city in June 2008, Southampton Coroner's Court was told.

The first day of the inquest heard he was sent to look at a ballast tank that his superiors thought was full.

But it was empty and he entered knowing the dangers of low oxygen.

First boatswain Mamerto Gomez gave evidence at the inquest, and said that on the 11 June surveyors were onboard to examine the ship's ballast tanks.

Mr Zordilla was told to go to tank four, with the command to taste the water inside to see if it was fresh or salt water, he said.

This would have been relatively easy if the tank had been full, the jury heard, but no-one was aware it was in fact empty.

The court heard crew members usually monitor water levels inside ballast tanks using a sounding pipe.

Rescue attempt

But the pipe on the Saga Rose was blocked and the crew did not know tank four was empty.

Jurors heard Mr Zordilla had years of experience and knew the risks of entering an empty ballast tank.

Crew members must be specially-trained to do so, have safety equipment as well as written permission because of the low levels of oxygen.

The inquest also heard from the ship's surveyor, Alex Toutountzis, who said ballast tanks were rarely opened except for inspections every two to three years.

Crew member Rex Layese also gave evidence about how he tried to rescue Mr Zordilla but nearly suffocated himself when he too entered the tank.

The inquest continues.

Story from BBC NEWS:
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Re: Assumption Kills

Post by Pacific Barbarian »

There really is no excuse for this. ENCLOSED SPACES KILL posters are posted all over in the accomodation on our vessels. SMS is in place. PTW everybody MUST be aware of as it is part of the new joiner safety introduction, which is conducted by a senior officer on board. Regular safety meetings to be held with all crew present. I mean, all the paperwork is a pain in the ass, but the checklists to be ticked, signed and displayed under active permits on the bridge is for YOUR SAFETY! Lets not even go to Jobs Safety Analysis and Calculating Risks! Once again, pain in the ass, but sure makes you think about things and prevents complacency from setting in. It really is a disgrace to lose a life like this at sea, cutting off bread supply to families at home, losing a loved one. PRIORITIES :evil:
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