Deck layout: hazardous by design!

Initial report

A lumber carrier embarked a pilot as it approached a loading berth where a tug waited to assist. The pilot requested that the vessel secure the tug’s line to the mooring bitts on the forward deck. After this was achieved, and as the tug came under the line to push up, the tug master realised that his line had been improperly secured: it had been wrapped around the bitts and secured with a shackle, rather than the eye being dropped over the top of the bitts.

When questioned the master explained that, when lowered, the log stanchions were so close to the bitts that they obstructed the bitts. The master was informed that they should not use a shackle in future, and that the bitts should not be used when the log stanchions were lowered.

Log stanchion in the lowered position

CHIRP Comment

The vessel is relatively new, and the deck layout has not been modified since she was built. This suggests that the improper placement of the log stanchion and mooring bitts is the product of poor design. This is known as a latent error, and CHIRP believes that there is a high probability that incidents will continue to occur on the vessel because the mooring bitts cannot correctly and safely be used as intended. The likelihood of an incident is further increased because of the proximity of the bulwark brackets which create a trip hazard.

The trip hazard and inability to correctly work the mooring bitts are evident, and CHIRP is concerned that these had seemingly not been detected either during commissioning trials, during flag and class inspections, or by the crew themselves. CHIRP is also concerned that other vessels of the same design might also contain the same latent design hazards.

Human Factors relating to this report

Design (latent factor) – Eliminating poor design from ship construction requires an experienced design team who can understand human centred design and make life easier for those that have to work with the equipment. Removing poor design will improve safety for the crew, ship and environment and lead to better productivity over the life of the ship.

Capability – Was the naval architect aware of the ergonomic implications of placing the items too close together, and the trip hazards created by the bitts being placed so close to the bulwark brackets? If compromises were made due to the lack of space, were these highlighted in the construction and use documents so that they could be brought to the crew’s attention?

Culture – Did the company’s safety reporting culture empower the crew to report design issues and other concerns? Was there a culture of reporting on this vessel?

Many well-run companies operate a top-down and bottom-up culture where the voices of those that must operate equipment can be heard and something is done about their concerns. Does this describe your organization?

Communications – Did the crew feel empowered and confident to raise concerns about the design of the deck layout? Did they believe that their report would be acted upon, or did they feel that their concerns would be discounted?

Report Ends…………………..