Update Sep 2006

Why are documented procedures and checklists not the solution to avoiding frozen fuel oil in deck lines?


A story about an error to inform the vessel:
A shipping company which owned a small fleet of Panamax tankers faced the following situation:

Relevant Facts:
The ships had been purchased within the past year and were medium age, high quality vessels. Two of them had deep well pumps.
During their first winter of service in the Atlantic, two of the vessels were loaded with similar cargoes and made similar voyages to deliver their cargo to US East Coast ports. They loaded viscous fuel oil in warm climates and discharged the fuel oil in freezing January conditions.

One vessel had an easy discharge but the other did not
Over the past year, the Superintendent Engineer was busy taking control of the fleet. Understandably, a significant portion of his time was used getting truly familiar with the maintenance condition of all considerable machinery on the vessels in an effort to get the vessels up to company technical standards. These vessels generally have more machinery than conventional tankers, so this created even more work than usual.

These vessels were slightly different in operation than conventional tankers as they were deep well pump vessels with double bottoms. These differences made stripping much easier, needing less trim, whilst factors like heating and pumping were of course much more complicated.

The Superintendent Engineer did his utmost to guide the masters and chief engineers in order to collectively anticipate potential problems; certainly the issue of clearing deck lines of cargo in freezing weather was one area that had been covered extensively. However, one vessel had been taken over more recently and the hydraulic cargo pumping system was attracting more of his attention, while warnings regarding the stripping of decklines during discharge took a secondary position.

Because of the attention given to the hydraulic system, the problem in the damaged vessel was simply due to an inadequate level of attention and precaution with respect to the best procedures for discharging fuel oil in freezing weather.

As a result, this vessel allowed partial discharge of its tanks into lightering barges instead of insisting on full discharge. In other words, the vessel, in its discharge plan, allowed some tanks to remain partially filled while the barge discharge was interrupted.

This is an ill-advised judgment, as it requires a better flushing of deck lines after cargo operations are interrupted. Conversely, the first vessel had taken the precaution to empty each tank fully within each lightering operation.
What factors does this situation highlight, which would have been relevant to prevent the poor discharge performance of the second vessel?

Effective documents require:

Appropriate Content: Do documents succeed in delivering ideas completely or are they often too convoluted or irrelevant for the issue at hand? Had the masters of the above vessels looked in the SMS manuals, they would have read through countless non-applicable warnings, recommendations, and obvious statements best reserved for contractual agreements. What they needed was know-how exchange.

Timeliness: If documents are not automatically prompted to appear at the time of need, it becomes the responsibility of the person to retrieve the correct information at the appropriate time. Citing the situation above, if the master of the second vessel was expecting trouble discharging he may have spent time trying to find know-how related to the cargo vessel and circumstances. However, retrieval is an effort that must be remembered.

Awareness of the forms: We cannot expect people to retrieve documents that they have either forgotten or never knew existed. For the most part, people will remember items if they are listed as a tick-box in a checklist. However we are relying on the memory to remember the checklist itself.

Other considerations that address the reality of these situations:

  • How long do people need in order to consistently remember a new checklist or a new set of checklists?
  • How long are the quality management folks frustrated by masters' unreliable memories as regards forms and checklists?
  • How realistic or rational is it to expect people to remember the right form if there are different checklists for each cargo/voyage/vessel layout/charterer? 

Using checklists to time the delivery of warnings:
A checklist is a document that lists and orders items that must be remembered as compulsory stages in executing a process. Assuming the user has been trained to remember the checklist, tick-boxes help remind users of things they might otherwise forget. While checklists are essential in accomplishing complex tasks, here are some important considerations:

  • Are people seeing the checklists before making important decisions?
  • Are the appropriate checklists considered when decisions are made?
  • What if the process is often different from the standard? Examples include:
  1. Taking appropriate bunkers for draft restricted ports and varied voyage range and varying bunker prices in different ports.
  2. Deciding whether the vessel needs a repair to the hold bilge valve before going to sea with the holds loaded.
  3. Determining whether it is prudent to carry out hot-work on the IGS line while most of the crew are preoccupied with gas feeing and tank cleaning on a tight schedule
  • Is there a separate standard process checklist and a special process checklist?
  • Is there a checklist for every status change that could vary the process?
  • Are there tick-boxes that people tick without careful consideration? For example, a seaworthiness checklist may have a list of the ship’s systems which must be in order. Do people really think about the complexity of the system before ticking the box? Or, if the checklist has tick-boxes for dozens of subcomponents for each system, do people really concentrate when ticking each one?

In reality, the storage, retrieval, and delivery of documents is only a small aspect of the success of using documents. What else do we really need?

  1. We need to learn new processes;
  2. We need to always be cognizant of items that cause risk infrequently, but if ignored, result in severe consequences;
  3. We need to capture steps in due diligence to demonstrate competence to third party stakeholders;
  4. We need to collaborate between groups, announce concerns, and focus the collective attention of interested parties on the relevant issues;
  5. We need to collaborate and share ideas to find solutions; and
  6. We need to encourage the development of new ideas by differentiating thoughts through writing.

Is Task Orientation a solution in knowledge management?

  1. The consolidation of all filtered information related to your task is essential in imparting SMS related information to people joining the vessel. It is also important for conveying current, dynamic information to those undertaking complex or time-sensitive tasks, even when they are highly familiar with the SMS.The alternative to employing a Document Management System requires a user to remember to examine the contents of countless files to cover all information relevant to a complex task. Not only are these systems impractical, but they are only as good as the memories of the people who use them.Information that you unaware of, but that is nonetheless vital to your task is easily accessible when using the Task Assistant.
  2. The alternative Document Manager requires: Knowledge of the existence of forms with a title that indicates a connection to what you are about to do, and performing a text search; or looking through the entire contents of the files. This highly approximate approach that cannot be done unless there is a definite expectation as to the existence of relevant information.
     

So how could Task Orientation have helped our two deep well pump Panamax tankers to discharge their cargoes without complications?

  1. With Task Orientation, the warnings reminding the first vessel to be aware of the complexities of fuel oil discharge in cold weather using deep-well pumps would have simultaneously reached the other vessel because the information would be automatically indexed to all relevant tasks in vessels with deep-well pumps and fuel oil as cargo. The model based indexing of the Task Assistant would have easily prevented the problem.
  2. The warnings accessed by either vessel on their respective voyages would not include the following non-relevant warnings:
  • Warnings regarding other cargoes such as crude oils with light and viscous elements;
  • Warnings about conventional tanker’s discharging of viscous fuel oils;
  •  Warnings about clean cargo handling and IGS;
  • Warnings about the flushing of deck-lines on conventional pump tankers;
  •  Warnings regarding discharge into barges for conventional tankers;
  • Warnings regarding heating coils on conventional tankers instead of the deck heaters on deep-well pump vessels.

Whether these warnings were simply experience reports or items on checklists, the irrelevant warnings distract people from focusing on the ones that do apply. As we have seen, a system, which is congested with superfluous information severely, reduces the value and obstructs the original purpose of documentation.