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COVID-19 Improper Risk Management

As part of a scheduled vessel crew change, all on-signing crew members received a COVID-19 PCR test. Although all results were deemed negative, one test had failed to produce a valid result, and a new test was organised.  Giving due regards to the known results and following an assessment of the COVID-19 risks, marine and project management took the decision to sail, with the re-tested person effectively isolated onboard the vessel whilst awaiting the result of the PCR test.

Two days after departure, a positive PCR test result was received, resulting in the person having to remain isolated on board the vessel for 14 days. The isolation was well managed in line with the vessel’s COVID-19 outbreak management plan and there were no further infections reported.

Lessons learnt

  • Sailing without receiving all PCR test results was in direct conflict with the mitigations described in the original (approved) risk assessment for the crew change;
  • The risk of having a potential COVID-19 infected person onboard was assessed by the project management team in collaboration with the marine senior officers. The outcome of the risk assessment was not presented to senior management ashore for formal review, nor for approval;
  • There was no formal management of change to ensure that senior management (ashore) were satisfied that the risks had been evaluated and would be properly managed;
  • The person concerned was required to remain onboard to satisfy the vessel’s safe manning requirements, however, during the 14-day isolation that person was not available to perform normal duties;
  • The work site was approximately 300 nautical miles from port, which could have prevented the person receiving timely treatment in the event of complications arising from the COVID-19 infection.

Corrective Actions Taken / Recommendations

  • Where testing is carried out as part of the crew change risk mitigation process, all test results should be known before sailing;
  • Changes to a previously approved COVID-19 crew change risk assessment must be subject to a formal management of change (MoC) process, approved by senior management;
  • Due consideration should be given to the ability to provide adequate medical care for someone onboard whose condition may deteriorate rapidly;
  • Uncertainty about the medical fitness of anyone scheduled to sail on the vessel, should be resolved before sailing.

Members may wish to refer to:

Safety Event

Published: 2 February 2021
Download: IMCA SF 04/21

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