Deliberate failure to follow instructions: unsafe/quarantined tools brought back into use

  • Safety Flash
  • Published on 28 September 2020
  • Generated on 4 December 2024
  • IMCA SF 28/20
  • 2 minute read

What happened?

During a routine vessel inspection, crew were observed using a grinder with a selector switch as opposed to a paddle switch, which was contrary to procedures and communication from previous incidents and safety bulletins.

During a routine vessel inspection, crew were observed using a grinder with a selector switch as opposed to a paddle switch, which was contrary to procedures and communication from previous incidents and safety bulletins.

What were the causes? What went wrong?

  • Upon investigation, it was discovered that the vessel had the approved (paddle switch) grinders on board, but they were seen as being too bulky for the job; the crew removed the old grinder (smaller size) from the quarantine box and put it back into use.

  • On inspection of the quarantine box, it was noticed that there was no manner of securing the box in order to prevent someone from accessing quarantined equipment.

  • Inadequate supervision, to ensure equipment designated inappropriate does not re-enter service – crew members deliberately used equipment that had been taken out of service.

Actions

  • Devices in “quarantine” should be rendered temporarily unusable or put strictly under lock and key.

  • A hazard hunt was carried out to ensure that selector switch grinders were no longer in use.

Members may wish to refer to the following incidents; they are at first appearance dissimilar to the above – but they are all as a result of deliberate failure to follow instructions or procedures. In one case a written warning followed:

  • Personal Injury Following PPE violation and slip and fall on deck [vessel Master went to the main deck without safety footwear or a safety helmet]

  • Short Circuit On 440v Ac Bus Bars – Arc Flash [Crew deliberately ignored safety protocols to expedite what was considered an easy and straightforward task]

  • Lost Time Injury (LTI): Fall From Height [senior ROV pilot/tech fell while climbing off an ROV without using a ladder; the JSA identified that a ladder should be used]

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