Clipper Pennant. A near accident exposed the danger.
A safety flash followed.
The investigation was closed without evidence of effective follow-up.
In October 2020, a crew member on Clipper Pennant was seen standing in the path of a moving semi-trailer. The stowage space offered no escape.
On 28 June 2021, an internal ISM audit found another warning.
Risk assessments had not been adapted to vessel-specific work. The crew routinely used generic assessments.
On 20 July, the bosun was fatally crushed during cargo loading.
The management system was not short of signals.
The signals simply did not change the job.
During the fatal manoeuvre, the tractor driver lost sight of the bosun. The driver continued because this was not unusual. The local routine assumed the banksman would move behind the adjacent trailer.
That assumption had become the control.
The bosun did something different.
He remained on a painted walkway beside the accommodation bulkhead. The walkway looked like separation. It was not.
It sat inside the vehicle lane.
In stowage space 21, the paint reduced the effective lane width to between 2.35m and 2.41m. The semi-trailer was 2.55m wide.
A line intended to preserve access placed the banksman inside the vehicle path. The report found that it probably created a false sense of security.
Calling this individual non-compliance is incomplete.
There was no documented procedure for loading the more hazardous corner spaces. The operator and charterer knew about the workaround. Neither stopped it. Neither had completed a risk assessment or safe system of work for it.
Their procedures had not been formally aligned for the charter.
Meanwhile, the bosun was expected to marshal trailers, lash cargo and supervise safety. When he concentrated on marshalling and lashing, the upper vehicle deck had no effective supervision. There was no CCTV there to provide another view.
This is how a workaround becomes normal.
The driver expects the banksman to disappear.
The banksman expects paint to provide space.
Management expects separate procedures to work together.
Each assumption appears workable until one person behaves differently.
For a DPA, the useful test comes before closing a near-accident report.
Do not ask only whether an action was assigned.
Return to the deck.
Observe the same manoeuvre.
Confirm where the banksman stands, when the driver stops and whether both organisations use the same method.
Then verify that the workaround has actually disappeared.
What evidence does your SMS require before closing a corrective action: confirmation that an instruction was issued, or proof that the work changed?
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