The procedures for connecting and disconnecting the import hose and disconnecting from the CALM buoy in place on board Karratha Spirit were signed off as being satisfactory and reflecting shipboard practice, but they had not been effectively reviewed on board the ship. Consequently, the ambiguities in the procedures and the discrepancies between the procedures and the ship’s practices were not identified during any shipboard review or audit and were not made known to the ship’s managers through any review process.
The ATSB acknowledges the safety action taken by Teekay Shipping Australia to address this safety issue and is satisfied that the action will adequately address the issue.
The ATSB has been advised that the following safety actions have been taken by Teekay Shipping as a result of the accident:
• The importance of Risk Assessment and strictly adhering to documented procedures to be emphasized through a concentrated training campaign for the entire staff on both FSOs.
• Develop an induction package that highlights high risk operational tasks to be viewed by unfamiliar facility personnel prior to task being undertaken. Trainer to ascertain facility personnel’s understanding. Familiarisation to be recorded in current competency matrix. Drills to be undertaken on irregular high risk tasks (i.e. disconnection drill prior to cyclone season).
• The Management of Change process and parameters to be highlighted onboard the FSOs during an extraordinary HSEQ safety meeting.
• Conduct an operational audit of all FSO specific practices to ensure validity, compliance and alignment of procedures Loss of situational awareness
• The FSOs are to develop documented procedures that persons off watch may be called at any time for priority operations.
• Shore management to develop a means of ensuring facility personnel are effectively familiarised by experienced personnel prior to identified high risk tasks being undertaken.
• Such familiarisation is to be recorded in a manner that the Master (or designate) can identify the amount of experience the FSO has onboard, at any one time, for any one high risk task.
• Shore management in consultation with Master is to review competency matrix and identify task experience shortfalls, as per FSO training matrix and competency/induction matrix.
• Interview the Master, highlighting failures.
• Provide relevant training.
• Raise awareness regarding safe mooring practices and the dangers of being present within snap back zones.
• Communicate this incident as an extraordinary safety meeting to both FSOs to extract learning from the incident.
• Use the lessons learnt from incident to raise awareness during seafarer conferences, and ship visits.
