BULLETIN - Australian Maritime Safety Authority

Shaping Shipping
for People
February 2015
In this issue
Working at heights – defined 2
Learning from incidents –
Falls from height data
2008 to 2013
Working at Heights
Falls from height –
an alarming situation
Welcome from Allan Schwartz, General Manager of
Ship Safety Division
The broader safety
issues related to
working at heights
Welcome to the first issue of Shaping Shipping for
People. This bi-annual bulletin will identify trends
in maritime incidents and aims to raise safety
awareness in the industry. It will also provide advice
and recommendations on important safety issues
to seafarers, ship owners, operators and industry
groups. Safety trends will be examined in relation
to human factors research and relevant incident
investigations. The information presented should help readers identify
ways to improve safety on board their own ship or in their company.
This issue focuses on height safety in Australian waters. I trust you
find this bulletin informative and useful.
Safety culture – staying
within the safety boundary 4
Maritime Safety Awareness Bulletin, Issue 1, February 2015
Ensuring a learning loop
Looking ahead –
safety culture study
Take-away message
References 4
Useful resources
Working at heights – defined
When considering the types of tasks that involve working at
heights at sea, images of tall masts and deep cargo holds
often spring to mind. However, numerous tasks at sea involve
working at heights. Falls can occur anywhere on a ship, such
as, ladders, gangways, over the side and stairs in machinery
spaces. When adding slippery surfaces and ship motion to
the equation, the potential for accidents is high. Every year,
AMSA receives dozens of notifications regarding falls from
height at sea, for example:
• Two crew members on a bulk carrier were seriously
injured after falling eight metres in the cargo hold when
the scaffolding they were on fell over.
• A crew member on a passenger ship was killed when he
fell 24 metres when cleaning windows from a catwalk
outside the bridge.
• A crew member on a container ship died after falling four
metres when stowing a cargo crane hook.
• Two crew members were untangling fishing lines from the
accommodation ladder of a bulk carrier, when one of them
lost balance and fell overboard. The crew member was
out of sight within minutes and could not be rescued.
This issue provides an overview of falls from height statistics
and a discussion of how safety culture can reduce accidents
in this area.
Figure 1: View from the inside of bulk carrier cargo hold of similar size to
Hanjin Sydney (source: ATSB)
Falls from height data 2008 to 2013
Learning from incidents – example
On 2 February 2011, during cargo hold cleaning, the
boatswain on board the bulk carrier Hanjin Sydney fell about
25 metres from a cargo hold hatch coaming to the tank top
below. He died instantly as a result of the fall.
This tragic incident exemplifies safety culture issues, in this
case resulting in a fatality while working at height [1]. Safety
factors relevant to this incident included a failure to report
faulty equipment at the accident site; the assumption that
risks were understood and that risk assessments and work
permits for the task were not necessary; a failure to use a
harness or a ladder in order to save time and a personal
acceptance by the victim of the risk which he had warned
others about. This death was preventable had these aspects
been managed better. It is important that we all learn from
such incidents and implement processes that will help
prevent similar accidents in the future.
Between 2008 and 2013, 122 falls from height in the maritime
industry were reported to AMSA and the Australian Transport
and Safety Bureau (ATSB) (Figure 2). Eight of these were
serious enough to warrant an ATSB safety investigation.
These falls from height were generally the result of a
complex set of circumstances, often involving a number of
contributory safety factors.
70 60 50 40 30 20 10 0 Fatality Serious Injury 2008 2010 2011 Minor Injury 2012 2013 Figure 2: Number of fatalities and injuries due to falls from height 2008-13
(source: AMSA)
Individual factors Training Environmental factors 2
2009 Design/equipment Risk assessment/control 1 30 20 Safety factors identified from the falls from height data have been
and include individual factors, environmental aspects,
10 issues with design and equipment (such as maintenance),
0 shortfalls inFatality risk control measures
and policies and
Serious Injury Minor procedures
Injury 2008 2009 there
2010 was
2011 (Figure 3). In most
more2012 than2013 one safety factor type associated with each fall from height incident.
This situation is not only of concern to those directly involved,
0 but is also costly to the Australian maritime industry, with
2007-­‐08 2008-­‐09 2009-­‐10 2011-­‐12 falls from
height compensation
claims for2010-­‐11 the period 2012-13
amounting to almost two million dollars (Figure 5).
$2,000,000 Individual factors $1,500,000 Training $1,000,000 Environmental factors Design/equipment $500,000 Risk assessment/control $0 Policy/procedure 0 5 10 15 20 25 30 2008 2009 2010 2011 2012 2013 35 40 Figure 3: Number of safety factors identified in falls from height incidents
2008-13 (source: AMSA and ATSB)
To some extent, the larger number of individual factors identified
and reported by industry (highlighted
in Figure 3) suggests that
1 the broader organisational and safety culture issues are often
not considered during on board investigations. Most incident
reports take an individualistic approach to causality, usually
placing the responsibility on the last person involved in the
chain of events. In reality, incidents are generally the result of a
complex combination of factors which create conditions within
which the final action, mistake or error can occur.
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 Figure 5: Compensation paid for falls from height for ships under the
45 Seafarers Act for financial years 2009-14 (source: Seacare)
The broader safety issues related to
working at heights
Examining height safety is particularly important for the
maritime industry because of the inherent risks of working
aloft at sea, including slippery surfaces, extreme heights
and ship motion. As any seafarer will1 know, there are various
tasks on a ship that require working at height, which makes
controlling and managing the associated risks crucial.
The primary control measures currently in place are the ship’s
Safety Management System (SMS), permit to work processes
and seafarer training.
Falls from height – an alarming situation
Falls from height are one of the major categories of serious
injuries and fatalities for Australian seafarers. Data suggests
that the maritime industry has a higher percentage of fall
injuries and fatalities than shore based industries. Alarmingly,
Safe Work Australia (SWA) data (Figure 4) shows that the
incident rate (serious claims per 1000 employees) in the
maritime industry is possibly as bad and sometimes worse
than the construction industry, which is considered a ‘high risk’
industry in this area because it suffers the greatest proportion
of land based falls from height injuries and fatalities.
The Australian Maritime College (AMC) has carried out a
study on height safety with groups of seafarers [2]. This
study shows that safety procedures and training alone are
not enough to control and manage fall risks at sea. The study
identified that procedures are not always followed and short
cuts are sometimes taken, suggesting broader issues need
to be considered in height safety practice. Accordingly,
making improvements in these areas will likely reduce risks
associated with falls from height in the maritime industry.
Figure 6 (page 4) provides an overview of some of the broader
aspects which should to be considered when assessing the
risks associated with working at heights. Most of these were
also identified in the AMC study [2].
4 Mari/me Industry Construc/on Industry 3 2 1 0 2007-­‐08 2008-­‐09 2009-­‐10 2010-­‐11 2011-­‐12 2012-­‐13 Figure
4: Incident rate (serious claims per 1000 employees) for Water
Transport, Water Passenger Transport and Water Support Services
$2,000,000 $1,500,000 $1,000,000 3
Looking ahead - safety culture study
Safety Culture
AMSA considers safety culture to be crucial in managing
safety at sea and hence is funding a three-year (2013-16)
research study, in collaboration with two of Australia’s
leading universities, to assess the determinants of safety
culture in the maritime industry.
Environmental Conditions
Policy and Precudures
Risk Acceptance
Working at Heights
Time Pressure
Leadership and Supervision
Figure 6: Perceptions of deficiencies in height safety practice with some
identified in the AMC study [2]
Safety culture – staying within the safety
Safety culture is the encompassing critical safety aspect as
highlighted in Figure 6. One might think that we would have a
good handle on ‘safety culture’ by now, bearing in mind that
it is such a well-used phrase. Safety culture broadly refers
to the shared perceptions of safety policies, procedures,
behaviours and practices of seafarers and the organisation
in which they work. It is now well known that safety culture is
a significant determinant of safety outcomes and is a leading
indicator of accidents and injuries. Importantly, merely having
a safety procedure does not create a safety culture. In the
AMC study, seafarers identified that safety culture depends
on the attitude of the ship’s officers and that when superiors
are strict about safety the crew ‘fall into line’ [2].
A good safety culture cannot1 be established without clear
leadership and a prioritisation of safety. Effective leaders
promote safety culture, communicate clearly on safety
standards and hazard identification, and motivate the
shipboard team to make safety a priority. Conversely, leaders
who devalue safety and let safety violations slide, promote a
poor safety culture. Examples of poor safety culture include
allowing risk-taking behaviour to continue unchecked and
placing too much responsibility on individuals for their
own safety.
Comparatively little research into safety culture has been
carried out in the maritime industry. Therefore, there are
a number of unresolved issues that hinder improvements
in safety, noting that safety culture is considered to be an
important determinant of safety behaviour, accidents and
injuries in the workplace. Hence, a systematic assessment
is needed to investigate the influence of safety culture
on safety behaviour in the maritime industry. This work
will assist in the formulation of effective and evidencebased recommendations for the improvement of training
programmes, work design, procedures, policies and
regulations, and the assessment of safety behaviour.
Take-away message
It is possible to reduce the number of falls from height at sea
by addressing the broader issues in height safety practices.
Success of a safety culture depends on cooperation and
commitment from all involved and this commitment to safety
must come from the top. Leaders can start by ensuring all work
at height is adequately supervised, training is provided, workload
and fatigue are managed effectively and policies clearly prioritise
safety above time pressures. Seafarers can contribute by
following procedures, always using safety equipment, reporting
defects, not taking undue risks because it takes less effort and
remembering that even work that is done frequently can be
dangerous. Small changes, such as these, would have been
sufficient to prevent some of the accident examples given in this
bulletin. This illustrates the importance of taking the practical
lessons learnt seriously.
1. Australian Transport and Safety Bureau (ATSB) (2011), Crew
member fatality following a fall on board the bulk carrier Hanjin
Sydney at sea 2 February 2011, Canberra www.atsb.gov.au.
2. Boyle, A. and Brooks, B. (2012) Height Safety within the
Australian Shipping Industry: Perceptions and Practice,
Australian Maritime College, Launceston.
Useful resources
Ensuring a learning loop
• Australian Transport Safety Bureau (ATSB) – Marine Safety
Investigations and Reports. www.atsb.gov.au/marine.aspx
The most useful way of addressing problems with height
safety in the maritime industry is to address aspects of the
SMS. It was evident in the AMC study that SMSs need to
improve in capturing deficiencies through organisational
factors such as safety culture, supervision, leadership and
enforcement of procedures. Although further research is
required, it is clear that addressing safety culture first and
foremost is critical to reducing the risks of falls from heights.
• Comcare (April 2014) Slips, Trips and Falls.
• Alert! Papers, various issues
• Safe Work Australia (SWA) (October 2013) Work-Related
Injuries and Fatalities Involving a Fall from Height, Australia.