200753 - Hot work in vicinity of hydraulic systems

Hot work in vicinity of hydraulic systems	MARS Report 200753

Compiled from: Chirp feedback 1/2007: Issue no 14
 

On a vessel in drydock, a contractor was discovered carrying out hot work in the vicinity of the vessel's steering compartment whilst aft mooring hydraulic system was in operation. Had there been a hydraulic leak, there could potentially have been a fire and/or explosion. The conflicting work had been discussed at the daily work planning meeting, however it had been misunderstood by the contractor foreman.

 

The ship's safety officer suspended the hot work immediately and reported the near miss to the yard safety officer and master.

Root cause/contributory factors

1. Defective systems: the yard's permit to work system allowed hot work to be carried out in the vicinity of active hydraulic systems, without special precautions;
2. Poor communication: the venue of the daily work planning meeting was congested and the contractor foreman was too far away from the discussion to clearly understand the instructions.

Lessons learnt

1. Changes should be made to the safety management plan for vessel refits, or to the HSE elements of the contractual documents between owner and shipyards where they exist, to ensure that actuation of hydraulics, or transfer of other flammable fluids, forms part of the yard's permit to work system.
2. Consideration should be given to the venue of daily work planning meetings, including but not limited to, general location, noise levels, seating arrangements, essential attendees, policy on disturbances etc. Where these are able to be modified, it must be ensured that any key messages resulting form the daily work planning meeting are adequately
   passed to the yard workers and subcontractors. The use of daily toolbox talks would seem to be the best method.

Conclusion

In conclusion, the importance of adequate communication must be the significant root cause of this near miss - whether this is verbal or via posted information (including hot-work permits). The challenge is to ensure that all those involved in the repair of vessels in a shipyard are fully aware of the work of others and the systems still in operation. The efficiency of the permit to work system used by shipyards must also be vetted thoroughly, possibly as part of the HSE inspections already carried out to keep them on the approved list, and measures put in place to ensure that the recommendations are implemented.