Accidents happen when people don't communicate. In doing unauthorised work and not telling responsible officers, a safety-critical team leader (the bosun) short-cut the abilities and authorities of leaders responsible for the safety of planned work. 

What happened

On 23 June 2023 The bulk carrier Poavosa Brave was at anchor outside Tauranga Harbour, preparing to load logs. 
An on-board crane was hoisting stanchions (vertical posts for securing logs on the main deck) when the crane's block struck an able seaman. 
An able seaman was very seriously injured and was later evacuated to hospital by helicopter.

Why it happened

Under the operator’s safety management system the master and chief officer were responsible for safety assurance, including assessing risks and analysing the safety of planned work. The accident happened because the people involved didn't know what each other were doing.

• The master’s plan: At 0700, the ship's master allocated tasks for the deck crew. The master instructed the bosun not to use the ship’s cranes, partly because weather and sea conditions were unsuitable for crane operations.
• Bosun sets new plan – not communicated: By 1330 the conditions had eased and the bosun chose to start training the deck crew in using an on-board crane to hoist stanchions. The crew attended to the stanchions while the bosun drove the crane. But the bosun didn't tell the master or the chief officer about the change of plan and didn't seek the master’s authorisation to use the crane. The chief officer heard the crane operating, assessed the work as unsafe, and went to the deck.
• Back to the Master's plan – not communicated: seeing the crane block stationary on a hatch cover, the chief officer ordered the crew to retrieve it. But the chief officer didn't tell the bosun. The crew obeyed the order but it was unsafe because the bosun was still working to his plan, driving the crane. The ship began to roll on a sea swell, causing the crane block and hook to swing off the hatch cover and strike the seaman.

Accidents happen when people don't communicate

In doing unauthorised work and not telling responsible officers, the bosun short-cut the abilities and authorities of the master and the chief officer to assess the safety of planned work.

• Communicate the plan: The bosun should have told the chief officer and the master about the new work plan to use the crane. Those responsible officers could have prohibited the work or ensured everyone knew what they should do to stay safe.
• Double-check the plan is still the plan: If the chief officer and bosun had talked about the bosun’s new plan, it's very unlikely the chief officer would have ordered the crew into danger.
• Speak up: The crew should have spoken up to alert the chief officer about the risk, but they followed orders and said nothing because the chief officer outranked the bosun

What we can learn

Safety depends on following lines of authority. It's great to have a safety system that includes risk assessment and job safety analysis, but for that to work, responsible decision-makers need to be aware of all relevant information.

• If you're making a call to step in and stop something because you see it as unsafe, take a moment.
• Determine how to step in safely; don't introduce new hazards.

The full report is here: https://www.taic.org.nz/inquiry/mo-2023-204

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