200937 Breach of enclosed space entry procedure

Breach of enclosed space entry procedure
MARS Report 200937

While our tanker was moored alongside a lay-by berth for minor repairs, the attending port state control (PSC) officers observed work being carried out in an enclosed space (slop tank) without a nominated person standing by at the entrance. This observed unsafe practice constituted a major non-conformance with the company's SMS procedures, permit to work system and industry best practice. As a result, PSC recorded a deficiency, requiring the company to conduct a formal investigation into enclosed space entry procedures and inform the outcome to all vessels.
Result of investigation

Repairs were being carried out to hydraulic lines in the slop tanks. Initially, six separate activities were planned for the short port call but after conducting a risk assessment, two activities were cancelled to ensure adequate supervision could be maintained. Accordingly, a company superintendent was dispatched to the ship to assist.
In the permit to work, the second officer was assigned as watchman and supervisor for the enclosed space entry and repair job. During this time, the PSC inspection was also in progress. When the second officer was requested to attend the navigation bridge, he was relieved by an OS. Shortly after, the OS was relieved for a break by the duty AB, whose duties included the gangway security watch.
Some 15 minutes later, visitors appeared at the gangway head and this required the attendance of the duty AB, to comply with ISPS security procedures. While he processed the newly arrived visitors, the chief officer, accompanied by the PSC inspectors, arrived on deck and observed the work being conducted in the enclosed space without an attending watchman / linkman monitoring the safety of the occupants.
Root cause/contributory factors

Lack of planning and failure to inform PSC that the second officer was supervising work in progress inside the enclosed space, when his presence was requested on the bridge;
Inadequate supervision of the operation by a senior or other officer;
Insufficient personnel assigned for all the activities that were taking place;
Failure to temporarily suspend work inside the enclosed space during PSC inspection or until satisfactory manning levels could be assured;
Lack of appreciation of the importance of the stand-by watchman / linkman for monitoring personnel engaged in work inside an enclosed space.
What went right

Following the incident, all involved contributed openly to the investigation, allowing the investigation team to review the incident with clarity and arrive at appropriate recommendations.
Lessons learned

The appointment of a permanent stand-by watchman or link man at the entrance of the enclosed space should be clearly discussed by the supervising officer at the pre-entry conference, with emphasis on ensuring that he would not be distracted by, or engaged in, other activities during the enclosed space entry.
Risk assessments conducted for port calls should take into account the likelihood of unannounced or a demanding of visitors to the ship and ensure that adequate procedures (controls) are put in place to ensure sufficient numbers of staff are on duty at all time to cover statutory requirements.
Ensure all persons engaged in enclosed space entry procedures, and particularly those acting as link man, have been informed of their duties and understand them.
Editor's note: The report does not state if the AB manning the gangway was, in turn, properly relieved by another crew member. Although one can reasonably presume that the slop tank manholes were probably located in the immediate vicinity of the gangway, and that the AB could have supervised the personnel working inside the tank during the OS's short break, while also watching the gangway, under the ISPS Code those personnel assigned gangway security duty may not be assigned any other task.