HSSE LESSONS LEARNT 2021 Updated 29.11.2021

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GHSSE 16 - 2021

HSSE Incident - Lessons Learnt

Type of Incident: awareness and exercise extreme

High Potential Incident caution and be aware of risk

Brief Summary of the Incident: assessment of the impending

On 5 August 2021, around 1400 hours, transfer operation when conducting
while conducting personnel transfer by
pilot ladder at Galveston Offshore the transfer.
Lightering Area (GOLA), USA, the
platform handrail dislodged from the 3. It shall be the duty of the employer
retaining cup causing a Mooring Master
(Impacted Person) to lose his balance of a person who is exposed to the
momentarily. The Mooring Master was
able to regain his balance and step risk of falling into water and of
across to the platform, reseated the rail
and safely boarded. drowning to provide:

Impact: a. equipment and means of

The Impacted Person lost the balance rescuing and resuscitating
allowing the possibility of fall into water or
onto service boat which could result in drowning persons; and
serious injury or fatality.
b. suitable life jackets or other

equipment for keeping such

persons afloat in the event that

they fall into the water.

4. Persons embarking or

disembarking should maintain 3-

point contact at all times.

Active Failure

Accommodation ladder platform railing
was not secured in the retaining cups via
locking pin.

Finding: rig Figure 1: Location of Incident

Ship’s inability to properly
pilot/accommodation ladder for use

Lessons Learnt:

1. Officer in charge shall inspect the
rigging and securing of the pilot
ladder/ combination ladder on the
ship prior to any pilot boarding.

2. Due to physical nature of the Figure 2: Re-enactment of Incident
activity and the risks involved, all
parties should keep situational

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GHSSE 15 - 2021

HSSE Incident - Lessons Learnt

Type of Incident: led to no specific safety control in
place.
Lost Workday Case (LWC) 2. Markings on the cable for determining
the length was not practiced.
Brief Summary of the Incident: 3. Lack of intervention awareness.
4. Work area was not barricaded.
On 12 August 2021, around 1510hrs, a Lessons Learnt:
group of workers were in process of 1. All workers to exercise intervention to
connecting Dehumidifier (DH) cable. The stop any unauthorized personnel in
team had positioned themselves at the worksite or those not involved in the
trunk deck to lower the DH cable, IP and operation.
his colleague who were in the vicinity 2. Review the risk assessment for
came to their assistance. While lowering manual handling tasks.
the DH cable, there was a sudden jerk to
the cable which resulted the team to let Figure 1: Illustration of Incident
go the cable. Unfortunately, IP had been
pulled by the cable movement which
overthrew him from the trunk deck,
resulted him sliding down to the main
deck.

Impact:

IP sustained minor skull fracture and
various compression fracture on his
spine.

Active Failures

1. No intervention to stop unauthorized
personnel from entering the work
area and performing the job.

2. Workers failed to estimate sufficient
cable length causing them to
manually lower the cable using
hands.

3. DH cable not secured to any
structure.

Findings:

1. Specific risk assessment for DH cable
connection was not carried out which

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GHSSE 14-2021

HSSE Incident - Lessons Learnt

Type of Incident: function as intended (return to
Property Damage with High Potential neutral position automatically).

Brief Summary of the Incident: Findings:
On 19 July 2021 around 0855 hours, a 1. The Technician did not conduct
FSO Crane Operator (CO) began lifting a
cargo basket and swung the Starboard Planned Maintenance (PM) as per
pedestal crane boom over the water. As the Computerised Maintenance
the sector boat was positioning herself Management System (CMMS) task
towards the crane, the CO felt a jolt. list.
Then, crane boom suddenly descended 2. CMMS task list did not include
by itself until rested on the crane maintenance for the brake and hoist
platform. The sector boat managed to control lever as per maker’s
move away from the area and the cargo operating manual.
basket then sank into the water. 3. No verification of the pre-use
inspection practice at site.
Stop Work order was implemented, and 4. Original design of the crane does not
all planned lifting activities were have load-controlling mechanisms.
cancelled.
Lessons Learnt:
Impact: 1. Conduct periodic refresher briefing

1. Crane platform handrail damaged. on crane maintenance by competent
2. Crane is unusable for operation. person. The periodic refresher
3. Loss of cargo basket containing briefing should be included in the
training matrix.
scaffolding materials. 2. CMMS task list for crane specific
maintenance shall include all
Active Failure: maintenance activities as per crane
1. Crane maintenance was not carried maker’s recommended maintenance
manual.
out as per the maker’s maintenance 3. Perform periodical assurance to
manual. verify the adequacy of CMMS
2. Crane Operator did not properly checklists.
conduct pre-use inspection. 4. To perform study/ analysis with OEM
3. Hoist control lever was not input on whether installation of
maintained to ensure that it will ratchet pawl is feasible and required.

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Figure 1: Location of the Incident

Figure 2: Condition of Crane Boom Post Incident

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GHSSE 13 - 2021

HSSE Incident - Lessons Learnt

Type of Incident: 2. Wear the appropriate type of shoes
Lost Workday Case (LWC) for work which reduces potential slip,
trip and fall injury.
Brief Summary of the Incident:
While walking towards the water 3. Place cautionary signage over the
dispenser in the pantry, from nearby sink wet surfaces and use of non-slip mats
area, Injured Person (IP) stepped on a in appropriate areas. Consider
trace of water on the floor, then slipped providing bunds/ containments for
and fell. potential spill areas.

IP was immediately brought to the 4. Ensure all work areas (e.g.,
nearest clinic for medical treatment. workstations, pantries, walkways) are
clean and safe prior to
Impact: commencement of work.
IP sustained shoulder soft tissue injury
5. Report any potential hazards to the
Active Failures person in charge immediately or
1. Unsafe Condition: Spilt water from through Unsafe Condition Unsafe Act
(UCUA) reporting system.
the dispenser.
2. Unsafe Act: The spilt water from the Figure 1: Incident Location

dispenser was not mopped out nor
reported.
3. Failure to recognise the hazard (wet
floor).

Findings:
1. Pantry floor was not kept dry, which

resulted in slippery condition.
2. No report on the wet floor was raised.
3. There was no guidance or cleaning

equipment in the pantry for managing
spilt water/ wet floor.

Lessons Learnt:
1. Be aware of slip, trip and fall hazards

in the workplace, e.g., surau,
restrooms and pantries.

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GHSSE 12 - 2021

HSSE Incident - Lessons Learnt

Type of Incident:
Medical Treatment Case (MTC)

Brief Summary of the Incident:

While alighting from a 21-seater minibus,
IP lost her balance and twisted her right
ankle as her right foot accidentally step
onto the shoe of a co-worker in front of
her. IP was referred to a hospital for
further medical assessment and suffered
hairline fracture at the right ankle.

Impact:
IP sustained twisted ankle

Active Failures: Figure 1: Incident Re-enactment

1. IP failed to hold onto the handrail
while descending the bus steps.

Findings:

1. IP had both her hands free however
did not hold onto the handrail while
alighting from the bus steps.

2. IP was wearing shoes with 4cm
heels.

Lessons Learnt:

1. Use handrail if available or when
provided at all times.

2. Do not rush, be situationally aware
and maintain the safe distance.

3. Wear appropriate footwear
accordingly.

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GHSSE 11 - 2021

HSSE Incident - Lessons Learnt

Type of Incident: Lessons Learnt:
Lost Workday Case (LWC)
1. Conduct safety briefing or toolbox
Brief Summary of the Incident: talk on the correct method of
On 10 May 2021, a Wiper (Injured securing and recovery of ETOPs*.
Person, IP) sustained injury while Re-iterate the procedures for using a
retrieving Emergency Towing Off winch and taking stoppers when
Pennant (ETOP). heaving up heavy pennants.

Four personnel were involved in 2. New or inexperienced crew shall be
retrieving the ETOP at forecastle area, supervised when undertaking new
Starboard side. During the retrieval tasks.
process, three personnel repositioned
themselves, leaving the IP alone to hold 3. Ensure crew is always clear from
the pennant temporarily. IP dropped the wire / rope bights.
pennant on deck and as the pennant was
slipping out, IP attempted to hold it again 4. Do not attempt to stop or hold ‘out of
and the pennant to hit his left leg. control’ lines either by hand or by
stepping on.
Impact:
IP sustained fracture at left leg

Active Failures:
1. Failure to follow procedures of

using a winch and taking a stopper
when heaving up heavy pennants.
2. Poor coordination between the
team during the operation.
3. IP lost situational awareness and
was not attentive.

Findings: Figures 1 & 2: Position of the Crew Members

1. Toolbox meeting was not carried *The use of ETOP is not recommended by OCIMF. However, some terminals still
out effectively to discuss the risks require them to be rigged.
involved in the activity.

2. Lack of intervention and situational
awareness. The STOP work order
was not exercised when the crew
members did not follow proper
procedures of using a winch and a
stopper for heaving up the ETOP.

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GHSSE 10 - 2021

HSSE Incident - Lessons Learnt

Type of Incident: Findings:
1. Worker who controlled the rope was
Restricted Work Case (RWC)
inexperienced in vessel's door
Brief Summary of the Incident: removal and did not ensure the rope
On 11 May 2021, a worker (Injured in constant tension.
Person, IP) sustained an injury on his 2. The task was supposed to be carried
right foot. IP and his two colleagues were out by experienced subcontractors.
tasked to detach ship watertight doors. However, due to poor work planning
While detaching the door, it accidentally by Project Management Team
slipped downward and hit IP’s right foot. (PMT), the task was assigned to in-
IP was brought to the nearest hospital for house workers who were unfamiliar
further treatment. He was treated with with the task.
back slap (cast) and as outpatient care. 3. Due to the routine job, no risk
The IP is fit to work and has returned to assessment (Job Hazard Analysis)
work. was carried out specific for the task
which led to failure of hazard
Impact: identification resulting in this
incident.
IP sustained hairline fracture at
metatarsal area of right foot Lessons Learnt:

Active Failures 1. Identify a group of in-house workers
Use wrong method of work - use nylon who might involve in similar activity in
rope instead of chain block to secure future.
weather tight door and control manually
without tagline by inexperienced worker. 2. Conduct a refresher training on
related hazards and its controls, to all
identified workers.

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3. Ensure appropriate work method
based on the risk assessments
conducted, e.g. mechanical aids.

Figure 1: Location of the incident

IP

Figure 2: Reenactment of Incident

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GHSSE 09 - 2021

HSSE Incident - Lessons Learnt

Type of Incident: • The team did not ensure the ladder
was in good condition and secured
Lost Workday Case (LWC) properly at the location.

Brief Summary of the Incident: • IP and his colleague did not conduct
On 26 May 2021 around 1000 hours, a safe check/ inspection of the portable
general worker (Injured Person, IP) was ladder before using it.
assigned to set up an equipment for
Heavy Fuel Oil (HFO) tank cleaning Findings:
inside a cargo hold of a container ship. In 1. Risk assessment review and Job
order to access the HFO tank manhole,
IP took a portable ladder which was Hazard Analysis (JHA) during
available nearby the area. planning stage was inadequate, not
communicated to the team and
During ascending, the ladder slipped, hazards and risks related to safe
and IP fell onto the cargo hold floor from access and were not mitigated at
height of 1.5 meters. IP was sent to a site.
hospital for treatment due to the back 2. Supervisor did not verify site
injury and swollen leg. readiness is safe before starting the
work.
Impact: 3. Lack of awareness and safety
Spine burst fracture (L3), right heel precautions on ladder safety among
fracture and left ankle soft tissue injury team members and underestimate
the risks of ladder sliding.
Active Failures 4. Inadequate work planning to ensure
• Supervisor did not conduct specific well-maintained portable ladder is
installed and secured at site for
site assessment, verification, and workers to use.
inspection for safe access and
egress.

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5. Lack of safety culture with regards to Figure 1: The condition of the ladder’s sole during the
intervention and stop work policy incident
among team members.
Figure 2: The Wrong Positioning of the Portable Ladder
Lessons Learnt: (Upside-Down)
1. Enhance safety awareness, safety

culture and specific engagement with
workers especially foreign workers in
a small group (with translator). This
is to ensure consistent awareness,
knowledge and understanding on
hazard and its associated risks at
workplace.
2. Enforce strict compliance to
prohibition on using equipment other
than approved equipment,
3. Ensure temporary platform
installation for height above the
maximum length of extension the
ladder.
4. Implement HSSE Non-compliance
Management, i.e., counselling, and
one-to-one engagement.
5. Empower workers on Stop Work
order and UCUA especially foreign
workers.

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GHSSE 08 - 2021

HSSE Incident - Lesson Learnt

Type of Incident: On 19 February 2021, IP was sent to the
Lost Workday Case (LWC) hospital for examination and IP was
signed off the vessel and repatriated on
Brief Summary of the Incident: the next day.

On 17 February 2021 around 0230 hours Impact: IP sustained eye conjunctivitis,
LT, a Fourth Officer (Injured Person, IP) bronchitis, and anxiety disorder.
was instructed to work on deck for
changing over of cargo tanks for the on- Active Failures
going purging operations to reduce the 1. Venting of the H2S carried out via non
high Hydrogen Sulfide gas (H2S) content
in the cargo oil tanks. At about 0300 LT, approved arrangement i.e., tank
IP was exposed to high concentrations of dome instead of the purge pipe.
H2S on deck.
2. The H2S guideline in the Integrated
Second Officer (2/O), who was the Document Management System
Navigation Officer of the Watch (OOW) at (IDMS) was not referred to when
the time, noticed IP lean forward and sit preparing the Ship Specific Detailed
on deck. He notified available crew and Risk Assessment (DRA) for purging
called for assistance. IP was immediately of cargo tank.
pulled clear from the area by the Chief
Officer who was also on deck at the time. 3. The OOW did not intervene when
Chief Officer, Pumpman and IP were
Several crew members immediately observed on deck to open tank dome
responded and began administering First without donning the Breathing
Aid. IP assisted by crew was shifted into Apparatus (BA) set.
the accommodation where further
medical aid was given. IP recovered 4. Crew involved in the purging was
visibly, though a day later the sclera indirectly exposed to H2S vapour from
(whites of his eyes) started turning red. the tank dome.

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Findings: 5. Ensure strict compliance for non-
1. Venting of vapours was carried out routine activity process and
procedure.
from the tank dome instead of
approved venting arrangement. This 6. Intervention/ STOP WORK
was in contradiction to the company
policy of venting vapour only through recognised as one of the key barriers
the approved IG venting
arrangements. to prevent accidents and incidents. All

2. BA was not donned by IP or other staff and contractors have the
crew members during opening tank
dome with high H2S content. authority and obligation to stop any

3. Lack of communication and task or operation where an unsafe
instructions to the crew members
when venting activity was carried out. condition or action is observed, and

option to be exercised accordingly.

Lessons Learnt: Figure 1: Photo of Incident Re-enactment

1. Effect of exposure to high level of H2S
can be serious and life threatening.

2. Non-routine activity of H2S purging
shall be supported by risk
assessments and approved by
management prior to execution.

3. Non-routine activity shall be carried
out by competent and experienced
person and supported by buddy
system.

4. Adhere with safe work practices and
comply with PPE requirements.

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GHSSE 07 - 2021

HSSE Incident - Lesson Learnt

Type of Incident: Active Failures
NTPXII slipped off while repositioning
High Potential Incident due to the uneven surface of the tyre
fender, causing her to move parallel to
Brief Summary of the Incident: the vessel and resulted in the tug`s line
On 24th September 2020 morning, MT become taut and eventually parted.
FS Sincerity was under pilotage to Ocean
Berth #2 at Sungai Udang Port Sdn Bhd. Findings:
She was assisted by two tugs secured at 1. It was a delay in replacing of worn-
port bow and port quarter by tug’s line.
out tyre fender.
MT FS Sincerity in position with two 2. There was a lack of commitment
spring lines fast forward and aft. Both
tugs were instructed to push at 90- from contractor to replace tyre
degree angle and hold the vessel fender.
position alongside to the berth. 3. Maintenance was not adequately
performed as per contractor’s
While pushing, NTPXII (Tugboat) was maintenance regime.
drifted due to effect of the abeam current 4. There was lack of tug’s line planned
causing the tugboat bow pushing at the maintenance system monitoring.
slight angle. While attempting to 5. Inadequate tug’s line (polypropylene
reposition, the bow of the tugboat was rope) maintenance requirement in
slipped off from her position and moving the procedure.
parallel to the vessel with engine at 25%
of power. The tug’s line become taut and
parted at tug’s center lid causing minor
damage to the top railings.

Impact: Minor property damage with
High Potential.

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Lessons Learnt:
1. Replace parted tug’s line with a new

supply.
2. All damaged tyre fenders on board

renewed.
3. Develop a procedure for tug’s line

(polypropylene rope) replacement
criteria.
4. Develop a guideline on condition-
based monitoring of the rope to
determine residual strength.
5. Include mooring gears and fenders
as critical equipment in the
procedure.
6. Important to ensure the tugboat push
at the parallel body of the vessel.

Figure 1: Location of the incident

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GHSSE 05 - 2021

HSSE Incident - Lesson Learnt

Type of Incident:

Restricted Work Case (RWC) Active Failures

Brief Summary of the Incident: 1. The material transfer was out of sync
and both parties failed to secure the
On 20 June 2021 around 0820 hours, to scaffold pipe as they had loosened
facilitate scaffolding erection in the cargo their grip concurrently.
oil tank, a worker (Injured Person, IP)
was required to transfer a scaffold pipe 2. IP positioned himself in line of fire
measuring 6m in length and weighing during the material transfer.
about 20kg to a co-worker (Scaffolder) on
a scaffolding platform frame 4m above Findings:
the tank inner bottom.
1. IP currently undergoing on-job-
IP pushes the scaffolding pipe diagonally training and had 2 months of work
upwards along the transom to his co- experience.
worker who grabs and pulls the scaffold
pipe once within reach. Due to poor 2. As the task is repetitive and routine,
coordination, the material transfer was it causes the work group to be
out of sync and both parties loosen their complacent and failed to identify the
grip concurrently causing the scaffold hazards.
pipe to slide back down striking IP on his
chest. 3. Risk of scaffold pipe potentially slip
off during material transfer was not
identified in the Job Safety Analysis
(JSA).

Impact:

Hairline fracture on left first rib and IP
was given light duty.

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Lessons Learnt:

1. Prior to work commencement,
individual or working group must carry
out a dynamic assessment to ensure
safeguards are in place and body
positioning clear from the line of fire.

2. Enhance supervision and

enforcement of correct techniques for

material handling.

3. Routine review and discussion with Figure 1: Photo of Incident Site
the workgroup to ensure JSA is
updated, and control measures Co-Worker
implemented at site.
IP
4. On-job Trainees to work under close Figure 2: Photo of Incident Reenactment
supervision of their assigned mentor
and daily feedback to be provided.

5. Ensure adequate illumination at the
work location.

NO WORK IS SO URGENT THAT WE CANNOT TAKE THE TIME TO DO IT SAFELY

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GHSSE 04 - 2020

HSSE Incident - Lessons Learnt

Type of Incident: Lost Time Injury (LTI) Control (QA/QC) process before it is
confirmed safe for use.
Location of Incident: Offshore Platform
3. Each Site Activity Owner shall discuss
Date of Incident: January 1, 2020 work progress and its associated
hazards during toolbox meetings.
Brief Summary of the Incident:
Re-enactment of the Incident
An operator (Injured Person – IP) fell through a
wellhead hatch while doing housekeeping on
the main deck. IP stepped on a newly installed
hatch cover cap that is offset by only 5 mm
with the hatch opening.

The IP landed on the wellhead deck, 4 meters
below the main deck. The IP was referred to
the medic onboard and subsequently
evacuated to hospital for further treatment.

Findings: Figure 1: Before the Incident
1. New hatch cover was wrongly designed

and mismatched with the new hatch cover
opening.

2. Updated “As-Built” hatch drawing was not
available.

3. Team failed to recognize the potential and
associated hazards at the worksite.

4. Lack of supervision during the site survey
and fabrication works by Contractor.

Lessons Learnt: Figure 2: After the Incident
1. Raise Management of Change (MOC) for
Reference: PETRONAS Group, Health, Safety,
any modifications or changes, especially Security and Environment
for designs without the updated “As-built”
drawing.

2. Site Management shall ensure that the
modification done by Contractor
undergoes Quality Assurance / Quality

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GHSSE 02 - 2021

HSSE Incident - Lesson Learnt

Type of Incident: Findings:

Process Safety Tier 1 Pressure Vacuum 1. Ineffective recommendations
(PV) Breaker Gas Release
management, tracking and action
Brief Summary of the Incident:
item closure:
In December 2019, eight (8) tonnes of
hydrocarbon enriched inert gas was a) A Technical Safety Alert
released and subsequently detected at a
number of modules on a FPSO Kikeh. (issued in December 2014) on
The fire and gas (F&G) system
automatically activated the Emergency obsolete PV breakers no
Shutdown (ESD) system in accordance
with the Cause and Effects Matrix (CEM), longer to be incorporated into
resulting in power and process shutdown
and subsequent plant blowdown. All new designs and requesting
crew mustered and remained so until the
gas cloud had abated and the emergency the existing fleet to review
response team were sure that no further
leakages were present. whether the installed PV

Impact: Gas release resulting in plant breakers can be isolated/
shutdown and potential of fire and
explosion. removed from service. It was

Active Failures: Inadequate liquid level not communicated and
/ inventory and static head of water
resulted in a premature activation of the followed up effectively with the
PV Breaker at 1050 mm water gauge
Inert Gas (IG) pressure. Design relief set offshore fleet, which resulted
point of the PV Breakers is 2100 mm WG
if the design liquid inventory of 350 litres in the FPSO is still operating
is set and maintained.
with the conventional PV

Breakers in service for cargo

tank over-pressurization

protection.

b) A marine re-HAZOP was

conducted in January 2018

and a finding on PV breaker

issue had been raised.

However, the action item was

not captured in the hazard

tracking tool, which resulted in

no action items that were

identified in the re-HAZOP and

not resolved at the time of this

incident.

2. The planned maintenance (PM)

routine was not clearly worded and

resulted in not being followed

correctly.

a) The Computerized

Maintenance Management

System (CMMS) monthly

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assurance task PM procedure operations manuals and

was not followed. The PM Management System (MS).

required the PV breaker to be 2. The CMMS PM is to be

isolated and the liquid level updated to provide clear

verified and topped up, as instructions and guidance on

necessary. the operations and

b) The IG system design does maintenance tasks for PV

not allow for routinely isolating breakers. Frequency of

the PV breakers. Pipework inspection to be increased.

would have to be unbolted 3. Operations Audit Protocol and

and spades inserted. template to be reviewed and

c) The level within the PV revised to include the PV

breaker(s) could be breakers.

interpreted and topped up as 4. Recommendations, actions and

required without positively tracking of the same to be

isolating the PV breaker, but incorporated into the CMMS as a

the CMMS PM routine did not work order to ensure the structured

clearly state how this could be follow up until closure in the required

achieved. There was timeline.

insufficient guidance to the 5. Training and familiarization of

FPSO staff within the CMMS personnel in the operation and

PM. maintenance of the PV breakers to

d) Verification of critical be included in the competency matrix

assurance tasks to support and training materials.

health of Main Barriers

(identified in the Safety Case

Bow Ties analysis) was not

covered in the marine audit.

e) Critical training on operation

and maintenance of PV

Breakers is not incorporated

in the Company competency

assurance system.

Lessons Learnt:

1. Safety Alerts are to be incorporated Figure 1: Port Inert Gas Header PV Breaker
into the Operations Management Of
Change (MOC) procedure.
Recommendations and action items
from all resources (i.e., audits, safety
alerts, Safety Case, industry
guidance, Class societies, regulatory
bodies, etc.) are to be reflected in the

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[Confidential (Internal)]

GHSSE 01 - 2021

HSSE Incident - Lesson Learnt

Type of Incident: did not show any apparent
deteriorations.
Serious Injury Leading to Fatality c) Industry norm is to accept third
party/tugs messenger line
Brief Summary of the Incident: when offered.

On 20th August 2020, a vessel 2. Limited guidance on warping
completed her cargo discharge operation operation.
and was preparing for departure. During a) The aft mooring station team
the unmooring operation from jetty, the assumed that each member
aft station team was preparing to make understood the operations and
fast the aft tug and the Able-Bodied did not counter check with
Seaman (AB) (Injured Person - IP) was each other nor comply with the
tasked to tend to the messenger line on cautionary guidance in the
the winch end warping drum, which was SMS.
being used to pick-up the tug’s line. While b) The Detailed Risk Assessment
heaving in, the tug’s messenger line (DRA) procedure had not
parted, the IP was found lying identified any specific risks
unconscious on deck in close proximity to related to the warping
the warping drum. First Aid was operation.
immediately administered onboard and
he was later taken to the nearest local 3. Lack of enforcement and failure to
hospital. At the hospital, the IP’s vital exercise Stop Work due to perceived
parameters had stabilized. On 16th insubordination.
September 2020 after 26 days of a) The aft mooring station team
hospitalization, IP’s condition failed to exercise stop work on
deteriorated, and he passed on. the heaving up activity when
messenger line was under
Impact: Single Fatality tension.
b) The BELTSUP guidance
Findings: stipulates all instructions shall
be from the Officer in-charge
1. Messenger line (OOW).
a) The tug’s messenger line
failed at 23.75% design load 4. Poor communication among the
based on the lab test results. crew onboard.
b) The aft mooring station team a) Ineffective communication
accepted the tug’s messenger between aft mooring station
line as its external appearance team and IP who was standing
in a blind sector.

NO WORK IS SO URGENT THAT WE CANNOT TAKE THE TIME TO DO IT SAFELY

GROUP HSSE

[Confidential (Internal)]

5. The position of IP while picking up 7. Every crew shall be reminded on the
the tug’s line use of Stop Card or Stop Work
a) IP was in a blind spot of winch through pre-joining checklist or
operator and officer in charge. appropriate process.
b) The entire mooring deck is
classified as a snap danger 8. To map BELTSUP against Stop Work
zone. policy and address the gaps.
c) IP potentially tending to
tangled turns on warping 9. To re-run on safe mooring campaign
drum. to ensure 100% full coverage for the
entire fleet crew.
Lessons Learnt:
10. The Person-In-Charge must be able
1. Consider utilizing own pick up rope of to communicate with his team
appropriate size and material if throughout the operation.
condition of tug’s line is
unsatisfactory. 11. The team may explore possibility on
the usage of blind spot mirror to
2. Officer in Charge must ensure improve line of sight.
sufficient slack is available prior
change of focus to another task. Figure 1: Photo of re-enactment of the incident

3. Winch operator shall ensure
synchronization of winch speed in
relation to the tension of the rope
during heaving in operation.

4. Conduct refresher briefing/ training to
all new sign crew on high-risk
operation.

5. Conduct specific risk assessment on
high-risk operation (warping) and
review current procedures (mooring)
aligning with industry best practices,
recommendations and lesson learnt.

6. The mooring team must exercise
STOP WORK if it is deemed to be
unsafe during the operation.

NO WORK IS SO URGENT THAT WE CANNOT TAKE THE TIME TO DO IT SAFELY

GROUP HSSE