Deliberate failure to follow instructions: unsafe/quarantined tools brought back into use
- Safety Flash
- Published on 28 September 2020
- Generated on 11 December 2024
- IMCA SF 28/20
- 2 minute read
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What happened?
During a routine vessel inspection, crew were observed using a grinder with a selector switch as opposed to a paddle switch, which was contrary to procedures and communication from previous incidents and safety bulletins.
What were the causes? What went wrong?
- Upon investigation, it was discovered that the vessel had the approved (paddle switch) grinders on board, but they were seen as being too bulky for the job; the crew removed the old grinder (smaller size) from the quarantine box and put it back into use.
- On inspection of the quarantine box, it was noticed that there was no manner of securing the box in order to prevent someone from accessing quarantined equipment.
- Inadequate supervision, to ensure equipment designated inappropriate does not re-enter service – crew members deliberately used equipment that had been taken out of service.
Actions
- Devices in “quarantine” should be rendered temporarily unusable or put strictly under lock and key.
- A hazard hunt was carried out to ensure that selector switch grinders were no longer in use.
Related resources
Members may wish to refer to the following incidents; they are at first appearance dissimilar to the above – but they are all as a result of deliberate failure to follow instructions or procedures. In one case a written warning followed:
- Personal Injury Following PPE violation and slip and fall on deck [vessel Master went to the main deck without safety footwear or a safety helmet]
- Short Circuit On 440v Ac Bus Bars – Arc Flash [Crew deliberately ignored safety protocols to expedite what was considered an easy and straightforward task]
- Lost Time Injury (LTI): Fall From Height [senior ROV pilot/tech fell while climbing off an ROV without using a ladder; the JSA identified that a ladder should be used]
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