WHO DEALS WITH A DEFECTIVE MAST RISER SHUTOFF VALVE?
An example of how enhanced information flow through efficient document management can assist in avoiding omissions.
Vetting report: LIST OF OBSERVATIONS AND THE MANAGERS’ COMMENTS & CLARIFICATIONS THEREON
Is the cargo venting system, including inert gas lines, mast risers, high velocity vents and vent stacks in satisfactory condition?
Breather (P/V) valve, at base of mast riser, was tested during the inspection but the (manual) check-lift “lever” was not engaging the internal weight. Also the “lever” subsequently got jammed in the vertical position and could be brought back to neutral position.
Recently the upper stopper was found bent and the engineers who had faired it re-welded it a few millimetres away from where it had previously been. As scheduled routine maintenance was not far away the repositioning was left in abeyance until then and all crew members that would have handled this equipment were made aware that they should not push the lever to the very end.
The inspector not being aware of this pushed the lever as far as it would go thus causing the dislocation.
The upper stopper has now been repositioned and during several subsequent tests the equipment functioned without problem or hitch.
It was easier for him to send me a copy of the deficiency so I have included it above.
It is fairly clear from the above that a number of people are stakeholders and internal service providers in such a deficiency both in preventing it and in providing a remedy: The master, the safety officer, the fitter, the quality manager, the marine superintendent, chartering manager, etc.
It is also clear to those of us involved in tanker management that such an issue is very serious from a series of standpoints.
- Why was such an issue so poorly co-ordinated that the safety officer had not marked in the body of the riser a cautioning note about the temporary repair?
- Why was it not made clear to the inspector the plans for permanent repair and the temporary measures so that the inspector made a report more in keeping with the real situation?
- Why was such a safety critical item not brought to the attention of the marine Superintendent and Quality Manager and why was it eventually the vetting inspector who brought it to a wider audience?
The above is a very serious co-ordination issue that can be solved in two ways.
One is to have a marine superintendent that is so well informed about the condition of the vessel as to be able to gather absolutely all information and co-ordinate all the other stake-holders and internal service providers. The problem here is that the superintendent has to worry about five vessels whereas the master has only one to worry about. However, the master does not direct machinery repairs and out of service repairs, without the participation of onboard engineers and the superintendent. Also the master has many other matters to prioritise.
So such a matter requires responsibility at various stages.
- The onboard safety officer must detect these defects and warn the master and the quality manager.
- The quality manager must have a priority list of outstanding safety deficiencies and must communicate these with the marine superintendent to find out when they can be satisfied and if the repairs require special out of service measures, a matter that seriously affects chartering.
- The Master who is in charge of the safety of the vessel must ensure that the safety of the vessel is not jeopardised at any time between the time of initial detection and the time of final remedy. Therefore the master must make sure that he himself, the fitter, the safety officer and possibly the superintendent, design a remedy that satisfies all stakeholders. For instance does a permanent repair require the ship to be out of service and should the Chartering manger be informed? Actually in this case it did not require any out of service time because the valve could be removed and repaired in a safe area of the vessel. This is because the vessel was fitted with individual tank PV valves so the common IGS piping system leading to the mast riser could be blocked off without needing a special out of service period. However the master must discuss this process with the fitter first while keeping the superintendent informed, and pass the matter for approval to the onboard safety committee.
The above is just an example of an item needing co-ordination of many members of the ship management team onboard and ashore. Each company may have a slightly different process for resolving such a matter but all companies are vulnerable to such matters remaining incompletely resolved as in this case.
So how can we prevent action remaining in abeyance as a result of too many people being involved and too little co-ordination between them?
The answer is simple; we need to let the common sense of the marine personnel help to get the matter resolved with minimum fuss but we also need to catch the omissions that common sense people tend to make from time to time.
For example; if the defect is mentioned by the safety officer on a defect report, the quality manager will catch the omission if the defect becomes overdue. This is because the quality manager can be part of a workflow of defect reports related to safety.
Furthermore the safety officer on board would normally report resolutions of the safety meetings with respect to hot-work to the quality manager. So the attempts to repair the valve, as well as the final repair plan, would be information that would be clear to the safety officer and the quality manager as well as to the master and others who would actually implement the repairs.
With the safety and quality manager having a defined process of defect reporting and resolution, they are likely to more easily identify the problems with an interim solution, such as a SIMPLE sign to instruct crew and inspectors not to push the opening lever too far.
Furthermore a documented defect report from the safety officer would give the vetting inspector some confidence in the safety consciousness prevalent on the vessels.
For those of us in the Tanker business this is a good way to do business.
So we could spare the busy master from the additional burden of reporting safety defects, and involve those that are responsible for this (safety officer and quality manager) to manage the sharing of information via defect reports. So the busy multi-tasking master and superintendent can go about finding a quick solution without being burdened by bureaucracy while the mandatory bureaucracy can offer distinct value in minimising omissions such as the omissions allowed in the case described and reiterated below.
- Why was such an issue so poorly co-ordinated that the safety officer had not marked in the body of the riser a cautioning note about the temporary repair. This could have been solved by a more methodical involvement of the safety officer via a reporting procedure for such defects.
- Why was the inspector not made aware of the plans for permanent repair and the temporary measures, so that the inspector might make a report more in keeping with the real situation. This could have been solved by a more methodical involvement of the safety officer via a reporting procedure for such defects.
- Why was such a safety critical item not brought to the attention of the Quality Manager and why did the vetting inspection become the medium of awareness to the wider audience? This could have been solved by a more conscious methodical involvement of the safety officer and consequently the quality manager via a reporting procedure for such defects.
In all the above cases, a formal reporting procedure via the two most relevant roles in the company would not add burdensome or impractical bureaucracy, and would not add work to the multi-tasking roles of the Master and Superintendent.
A cautioning note: adding formal reporting via electronic forms can assist in avoiding omissions but the system must be very well designed and very intuitive. As many companies have discovered recently, electronic document management requires immense ergonomic design advancements.
Ulysses and its clients feel that this ergonomic obstacle has been overcome successfully and uniquely by the Task Assistant.