Deliberate failure to follow instructions: unsafe/quarantined tools brought back into use

What happened?

During a routine vessel inspection, crew were observed using a grinder with a selector switch as opposed to a paddle switch, which was contrary to procedures and communication from previous incidents and safety bulletins.

What were the causes? What went wrong?

• Upon investigation, it was discovered that the vessel had the approved (paddle switch) grinders on board, but they were seen as being too bulky for the job; the crew removed the old grinder (smaller size) from the quarantine box and put it back into use.
• On inspection of the quarantine box, it was noticed that there was no manner of securing the box in order to prevent someone from accessing quarantined equipment.
• Inadequate supervision, to ensure equipment designated inappropriate does not re-enter service – crew members deliberately used equipment that had been taken out of service.

Actions

• Devices in “quarantine” should be rendered temporarily unusable or put strictly under lock and key;
• A hazard hunt was carried out to ensure that selector switch grinders were no longer in use.

Related Resources

Members may wish to refer to the following incidents. They are at first appearance dissimilar to the above – but they are all as a result of deliberate failure to follow instructions or procedures. In one case a written warning followed.

• Personal Injury Following PPE violation and slip and fall on deck [vessel Master went to the main deck without safety footwear or a safety helmet]
• Short Circuit On 440v Ac Bus Bars – Arc Flash [Crew deliberately ignored safety protocols to expedite what was considered an easy and straightforward task]
• Lost Time Injury (LTI): Fall From Height [senior ROV pilot/tech fell while climbing off an ROV without using a ladder; the JSA identified that a ladder should be used]