Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2175
Initial Report
When inspecting the cargo securing equipment, our reporter discovered that a large number of base locks and twist-locks were worn and no longer fit for purpose. They reported this to the master, but no requisition was raised to the company.
Our reporter remained concerned because stevedores from other countries frequently reported issues with automatic twist lock malfunctions during cargo operations, resulting in delays. Moreover, the company had lost many containers overboard only a few years beforehand. Despite these ongoing concerns, the base lock issue remained unresolved. The nautical and safety superintendent was unaware of the twist lock conditions on the ship, and there had been no requisition raised in the planned maintenance system (PMS) program for some time.
Our reporter approached CHIRP for assistance because they were worried that containers could be lost overboard if they were not correctly secured. CHIRP approached the company, which cited a breakdown in communications with the ship and immediately arranged for the replacement parts to be sent to the ship.
CHIRP Comment
According to the World Shipping Council, in 2022 there were 661 containers lost at sea. Although this is a tiny percentage of the 250 million containers transported annually, each represents a hazard to the ship, and a general navigation and environmental pollution risk, quite apart from the financial loss of the contents.
The security of the cargo is a significant safety factor for the ship, crew, and the environment. It requires the highest level of attention to ensure it is carried out correctly. Internal and external safety management audits should identify equipment falling below acceptable standards. Additionally, ship manager visits should focus on these areas of cargo security. They must also adhere to and check the proper maintenance history in a PMS, and establish a realistic reordering stock level for cargo securing equipment.
The reluctance by the ship to report the state of the cargo-securing equipment to their management indicates the company’s poor reporting and safety culture. Given that container security issues in the past had been a problem, CHIRP notes that this should have been a high-priority matter. The reporting culture should be addressed promptly. Encouraging employees to speak out about safety concerns is vital and should be encouraged. A crew and other stakeholders that prioritise safety should be considered an asset to any company in the maritime industry. Safety should always be a top priority, and organisations must promote a culture where safety concerns can be raised freely.
The management company, Flag and the P&I Club were all informed of this report with a request that they check on the status of the cargo-securing equipment on this and other ships in the fleet. Guidance on securing containers, published by the Standard Club, can be found here: 3368203-sc-mg-container-securing-2020-final.pdf (standard-club.com)
CHIRP is happy to report that the company took positive action to address all the issues concerning cargo-securing equipment and has thanked CHIRP for bringing this matter to their attention.
Key Issues relating to this report
Communications – How easily can you raise a concern to management concerning a safety matter? How well do they respond to your concerns?
Teamwork – Encourage a shared mental model for cargo safety and alert each other when issues arise. This is needed on a large ship where checking on cargo securing items cannot be left to one person due to the sheer size of the vessel.
Alerting – Create a positive alerting culture so that risks for all operations are raised and actioned.
Culture – The company should look at how issues are raised with the company and evaluate the current state of its safety culture.