202458 'STOP work' doesn't translate well
As edited from TSIB (Singapore) report TIB/MAI/CAS.113
A vessel was underway in good weather. Two deck crew had been directed to paint the underside of the external stairway landings at bridge deck level. They were working from the boat deck and had been instructed to use a telescopic rod connected to a roller brush to reach the area to be painted several metres above. After starting the task, one of the crew decided to install a portable A-frame ladder (stepladder) to assist in the job. Using an A-frame ladder without a permit to work was contrary to the company SMS, but the other member of the painting party did not dispute this action.
Some time later, the vessel changed course and started rolling due to the change in angle across the swell. Suddenly, the ladder tilted towards the sea and the crew member on the ladder grabbed the drainpipe under the stairway landing with one hand to keep his balance. At the next roll, the ladder tilted again and this time both the crew member and the ladder went overboard.
The remaining crew member ran to the port side and threw the nearest lifebuoy towards the victim in the water as the vessel continued to steam ahead. He then raised the alarm with the bridge team. In short order a hard-over port turn was executed and the MOB position marked on the ECDIS. At the same time, broadcasts were made on the VHF to nearby vessels. By this time all remaining crew of the vessel had mustered and headcount was taken.
Lookouts using binoculars were posted to locate the victim and the rescue boat was readied. Within minutes, the lookouts located the victim in the water. As the vessel was manoeuvred close to the victim, he appeared motionless, floating face-up. A nearby fishing boat quickly recovered the victim, but he had no pulse. The victim was brought back on board the cargo vessel, but further resuscitation efforts were fruitless.
The investigation found, among other things, that the victim should have consulted the CO or OOW before using the portable ladder. Had he done so, the task could have been reassessed and a Risk Assessment and a Permit To Work process initiated for the use of the portable ladder. Also, there may have been a language barrier between the two deck crew members that hindered quick and concise communication.
Lessons learned
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Improvised plans can produce bad consequences. In this case the victim decided on a whim to use a step ladder, yet this tool required a permit to work (PTW) before use. The PTW, an administrative protection, would probably have ensured the proper installation of the ladder, thus saving his life.
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This company had a very innovative system to help crew initiate a ‘stop work’ effort; a whistle and STOP sign on a lanyard for each crew member. Yet, in this case it was not used. To facilitate a stop work initiative, not only must crew have the right tools, but they must be given proper training in their use and an environment of trust must be established.