SAC Report TG Huma 9 Jan 2014

No.
1 2 3 4 5 6 7 8 9 10 11 12 13
Name
JOL RIBUH ABDUL AZIZ KHAN MOHD ALFIERDAUS HANEZAN HASSAN AIZUL BIN ABU BAKAR ROSNI PAIZAL B. MAKHTAR MOHD MUSTAKIM BIN MADLA MOHD REZAL BIN ABDULLAH HALIM USRAH BIN KASIM MUHAMMAD HAFIZ BIN ABD. RAHMAN MOHD NAJIB BIN SHAMSUDIN MOHD NOH BIN JANIS ADI YUSLAN BIN ARPAH MOHD MARZUKI
Sex
M M M M M M M M M M M M M
Date of Birth Nationality

10/31/1958 8/30/1974 4/10/1983 10/13/1975 1/2/1980 5/25/1989 8/21/1972 11/21/1969 10/28/1988 5/29/1985 9/6/1975 3/5/1981 1/17/1982 MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN MALAYSIAN
Passport No.
K26825702 K26840225 A30515993 A22324366 A21210736 A27847936 A21419353 H26603918 A30522533 A30865300 H19591794 A28436461 A26026513
Date of Issued
2/13/2013 8/12/2012 8/19/2013 4/20/2010 2/4/2010 11/19/2012 2/23/2010 8/28/2012 25/07/013 9/13/2013 12/15/2011 2/1/2013 1/31/2012
Expiry Date of Passport

2/18/2018 8/2/2017 11/20/2018 4/20/2015 6/22/2015 11/22/2017 2/23/2015 1/11/2018 7/25/2015 10/13/2018 12/15/2013 2/1/2015 1/31/2014
Rank
MASTER CH. OFFICER 2ND. OFFICER CH. ENGR 2ND. ENGR 3RD. ENGR BOSUN AB AB AB OILER OILER COOK
NO
NAME
1 JOL RIBUH 2 ABDUL AZIZ KHAN 3 MOHD ALFIERDAUS HANEZAN HASSAN 4 AIZUL BIN ABU BAKAR 5 ROSNI PAIZAL B. MAKHTAR 6 MOHD MUSTAKIM BIN MADLA 7 MOHD REZAL BIN ABDULLAH HALIM 8 USRAH BIN KASIM 9 MUHAMMAD HAFIZ BIN ABD. RAHMAN 10 MOHD NAJIB BIN SHAMSUDIN 11 MOHD NOH BIN JANIS 12 ADI YUSLAN BIN ARPAH 13 MOHD MARZUKI
MASTER
CH. OFFICER
2ND. OFFICER
CH. ENGR
2ND. ENGR
3RD. ENGR
BOSUN
AB
AB
AB
OILER
OILER
COOK
Petronas HSEMS
Petronas CIMMV
MOPO
RANK
ZeTo
Guidelines during adverse weather
SMS Incident Notificationand Reporting
JSA, IPO and Toolbox HSSE Walkabout

Lesson Learnt from other Vessel
PTW System Introduction to OVID
Evident
Appraisee: Capt Jol Ribuh Date: 14-Jan-14 PROGRAM ACCEPTANCE AND CO-OPERATION
POOR FAIR AVERAGE
Additional Comments: He has mentioned about the JSA and Toolbox meeting are unpracticable . He hopes that the Office comes up with t tasks to do.
LEADERSHIP SKILL
POOR FAIR AVERAGE
Additional Comments: He is a good Master. He knows a lot about the Documentation and has a good control of the ship. But he is not a M officers on the documentation. He expect them to know by themselves.
CRISIS MANAGEMENT
POOR FAIR AVERAGE
Additional Comments: He also mentioned about the good relationship and rapport with the Barge or platform can defuse any crisis built u given to the barge/platform may help.
DECISION MAKING SKILL

POOR FAIR AVERAGE
Additional Comments:
EMERGENCY PREPAREDNESS
POOR FAIR AVERAGE
ACCIDENT/INCIDENT REPORTING SKILL

POOR FAIR AVERAGE
Additional Comments: He thinks that by sending emails is enough, instead of sending SOF or LOP, even after the relevant instruction in the
RECORD KEEPING SKILL

POOR
Not applicable FAIR AVERAGE
GOOD
EXCELLENT
e Office comes up with the manual which uses tick boxes for the
GOOD
EXCELLENT
e ship. But he is not a Master that can monitor and train his fellow
GOOD
EXCELLENT
defuse any crisis built up during operation. A few packs of cigarrette
GOOD
EXCELLENT
GOOD
EXCELLENT
GOOD
EXCELLENT
levant instruction in the CIMMV have been shown.
GOOD
EXCELLENT
Appraisee: Abdul Aziz Khan Date: 13-Jan-14 PROGRAM ACCEPTANCE AND CO-OPERATION
POOR FAIR AVERAGE
Additional Comments: NA
LEADERSHIP SKILL
POOR FAIR AVERAGE
Additional Comments: He is lack of leadership skill and seem to be difficult to control the Bosun. He is dependent to the Master and canno
CRISIS MANAGEMENT
POOR FAIR AVERAGE
DECISION MAKING SKILL

POOR FAIR AVERAGE
Additional Comments: He is dependent to the Master.
EMERGENCY PREPAREDNESS
POOR FAIR AVERAGE
ACCIDENT/INCIDENT REPORTING SKILL

POOR FAIR AVERAGE
Additional Comments: He is dependent to the Master.
RECORD KEEPING SKILL

POOR
Not applicable FAIR AVERAGE
Additional Comments: NA
GOOD
EXCELLENT
GOOD
EXCELLENT
o the Master and cannot be a good example to 2nd Officer.
GOOD
EXCELLENT
GOOD
EXCELLENT
GOOD
EXCELLENT
GOOD
EXCELLENT
GOOD
EXCELLENT
SHIP NAME DATE TIME TYPE OF REPORT LOCATION/PORT EVENT LOCATION 14-Jan-14 14:59
Non Corformance KSB Jetty Bridge Monkey Island Personnel Third Party Observation ASB Jetty Main Deck Accommodation Vessel Documentation HSE Walkabout KSB Anchorage Engine Room Galley Equipment Others
EVENT INVOLVES
DESCRIPTION OF EVENT
Observed that many anchor cable links has damaged at its centre.
EVENT LED TO
Personnel Injury Delay/Offhire
Vessel Damage Company Reputation
Equipment Damage Impaired Performance
DESCRIPTION OF THE CONSEQUENCES
The indication that the cables have worn out and the risk of loss of anchor is ev
DIRECT CAUSES
UNSAFE ACT UNSAFE CONDITION
INDIRECT CAUSES (PRECONDITIONS)

HUMAN FACTORS Fatique Lack of knowledge Lack of skill
HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Mentally/physically inadequate JOB FACTORS Inadequate leadership/supervision Inadequate maintenance Inadequate Engineering Inadequate tool or equipment
ROOT CAUSES (LATENT FAILURES)
Hardware Housekeeping
Design Defense
Procedure Maintenance
DESCRIPTION OF CAUSES
Lack of inspection regime.
CORRECTIVE ACTION TAKEN
SAC has advised the Master to generate Drydock Defect List.
ACCOMPANYING PHOTO
Not Applicable
HSE Walkabout KSB Anchorage Engine Room Galley Equipment Others ASB Anchorage Focsle Freezer and Chiller Cargo High Seas Focsle Deck For'd Dry Space Property Others Steering Flat Others Environment
amaged at its centre.
Cargo Damage
Property Damage
Pollution
and the risk of loss of anchor is evident.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Inadequate Engineering Inadequate tool or equipment
Inadequate Purchasing Inadequate work standards
Communication Incompatible goals
Organization Error enforcing conditions
Training
ock Defect List.
Great One Manjung 1 Great One Manjung 2 Icon Azra Icon Ikhlas Icon Samudera Icon Sophia Icon Zara Omni Anteia Omni Astrid Omni Emery
Omni Gagah Omni Marissa Omni Perkasa Omni Solaris Omni Stella Omni Tigris Omni Victory Tanjung Biru 1 Tanjung Biru 2 Tanjung Dahan 1 Tanjung Dahan 2 Tanjung Dawai Tanjung Gaya Tanjung Huma Tanjung Piai 1 Tanjung Piai 2 Tanjung Pinang 1 Tanjung Pinang 2 Tanjung Pinang 3 Tanjung Pinang 4 Tanjung Puteri 1 Tanjung Puteri 2 Tanjung Sari
Position of people- risk of falling from height Position of people- risk of staying under load Position of people- risk of contact with electrical current Position of people- risk of contact with hazardous substances Position of people- risk of being struck by object Position of people- risk of being caught in, on or between objects Position of people- risk of poor work position, overexertion Position of people- risk of encountering motor vehicle accident PPE- no head protection PPE- no eyes, ears, or face protection
PPE- no respiratory protection PPE- no hand protection PPE- no foot protection PPE- no coveralls at work site PPE- no safety harness PPE- no workvest/lifejacket Reaction of people- adjusting PPE Reaction of people- changing position Reaction of people- Rearranging job Reaction of people- stopping job/intervention Reaction of people- attaching grounds Reaction of people- performing lockouts Tools & equipment- using wrong tools for the job Tools & equipment- using tools incorrectly Tools & equipment- using defective tools May cause a fire Horseplay/boisterious behaviour Under the influence of alcohol or drugs Servicing equipment in use Operating equipment without authority Removing/Making safety device inoperatable.
Substandard of condition- design Substandard of condition- maintenance Substandard of condition- inspection Substandard of condition- wear & tear Substandard of condition- used beyond specification Inadequate guards or barriers Inadequate/improper protective equipment Defective tools, equipment or material Workspace restriction Hazardous environmental condition
High noise, high/low temperature Inadequate ventilation May cause a fire Poor housekeeping
EVENT INVOLVES
Observed that the Rescue Boat cannot retain the air due to major leakage.
EVENT LED TO
The rescue boat is not for immediate use. Hopefully the charterer did see this.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
The hole is too big to repair by use of repair kit on board or normal rubber glue treatment method. The wet air and dirts prevent proper bonding between two
The Master has already informed the Superintendent.
ACCOMPANYING PHOTO
Not Applicable
the air due to major leakage.
Cargo Damage
Property Damage
Pollution
pefully the charterer did see this.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
it on board or normal rubber glue. The repair has to be done by the Contractor by heat vent proper bonding between two surfaces.
tendent.
EVENT INVOLVES
Observed that the C/E does not fill up and put his signature in the ER Logbook s
EVENT LED TO
Non-conformance to the watchkeeping standards.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of interest to improve work standards.
SAC has informed 2nd Engineer to ask CE to update and sign on his ER Logbook
ACCOMPANYING PHOTO
Not Applicable
t his signature in the ER Logbook since 12/01/2014 until the 14/01/2014.
Cargo Damage
Property Damage
Pollution
ards.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
pdate and sign on his ER Logbook.
EVENT INVOLVES
Observed that the wornout sofa in the crew mess room that need to replace.
EVENT LED TO
Eye sore to look at. Poor living standard.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of interest to improve living standard on board.
SAC has informed the Master and Chief Officer. They agreed to generate SA on
ACCOMPANYING PHOTO
Not Applicable
mess room that need to replace.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
board.
er. They agreed to generate SA on this matter.
EVENT INVOLVES
Observed that the wornout sofa in the crew recreational room that need to rep
EVENT LED TO
Eye sore to look at. Poor living standard.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of interest to improve living standard on board.
SAC has informed the Master and Chief Officer. They agreed to generate SA on
ACCOMPANYING PHOTO
Not Applicable
ecreational room that need to replace.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
board.
er. They agreed to generate SA on this matter.
EVENT INVOLVES
Observed that the welding hoses still connected to the welding bottles after no
EVENT LED TO
Leaked oxygen and Oxythelene is very flammable. Risk of fire.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of awareness the risk involved with this equipment.
SAC has informed the Master and 2nd Engineer.
ACCOMPANYING PHOTO
Not Applicable
ed to the welding bottles after not being used. The broken gauges are still in use.
Cargo Damage
Property Damage
Pollution
able. Risk of fire.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
equipment.
er.
EVENT INVOLVES
Unused penant/wires remains on the spared towing drum.
EVENT LED TO
Eye sore to look at.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
SAC has discussed with the Master and CO. They agreed to discuss to the Super
ACCOMPANYING PHOTO
Not Applicable
towing drum.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
hey agreed to discuss to the Superintendent for the option to remove it from the ship.
EVENT INVOLVES
Sign of superficial corrosion on the towing pin steelplate.
EVENT LED TO
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of chipping/painting job.
SAC has discussed with the Master and CO. They agreed to chip/paint it when t
ACCOMPANYING PHOTO
Not Applicable
n steelplate.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
hey agreed to chip/paint it when the weather improves.
EVENT INVOLVES
Sign of superficial corrosion on the maindeck between the crash bar and shipsid
EVENT LED TO
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
ACCOMPANYING PHOTO
Not Applicable
between the crash bar and shipside including the rescue zone area.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
EVENT INVOLVES
Sign of superficial corrosion on the maindeck.
EVENT LED TO
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
ACCOMPANYING PHOTO
Not Applicable
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
EVENT INVOLVES
Sign of superficial corrosion on the focsle deck.
EVENT LED TO
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
ACCOMPANYING PHOTO
Not Applicable
k.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
EVENT INVOLVES
Sign of superficial corrosion on the rescue boat davit.
EVENT LED TO
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of painting job.
SAC has discussed with the Master and CO. They agreed to paint it when the we
ACCOMPANYING PHOTO
Not Applicable
at davit.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
hey agreed to paint it when the weather improves.
EVENT INVOLVES
Condition of ship hull: bare steel exposed. The missing tyre fenders.
EVENT LED TO
The ship may be held responsibility of the barge's yokohama fenders damage if
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
The area is constantly in contact with the yokohama fender.
Need to install tyre fenders when weather improves.
ACCOMPANYING PHOTO
Not Applicable
e missing tyre fenders.
Cargo Damage
Property Damage
Pollution
ge's yokohama fenders damage if it is puntured by ship rough surfaces.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
ohama fender.
proves.
Non Corformance KSB Jetty Bridge Monkey Island Personnel Third Party Observation ASB Jetty Main Deck Accommodation Vessel Documentation Information KSB Anchorage Engine Room Galley Equipment Others
EVENT INVOLVES
Observed that the Petronas HSE Manual is 2001 version.
EVENT LED TO
Charterer HSE requirement cannot be followed.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Monthly document check is not done correctly by responsible officer.
Advised CO to request the latest manual from the Charterer.
ACCOMPANYING PHOTO
Not Applicable
Information KSB Anchorage Engine Room Galley Equipment Others ASB Anchorage Focsle Freezer and Chiller Cargo High Seas Focsle Deck For'd Dry Space Property Others Steering Flat Others Environment
01 version.
Cargo Damage
Property Damage
Pollution
ed.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
y by responsible officer.
m the Charterer.
Substandard of condition- design Substandard of condition- maintenance Substandard of condition- inspection Substandard of condition- wear & tear Substandard of condition- used beyond specification Inadequate guards or barriers Inadequete/improper protective equipment Defective tools, equipment or material Workspace restriction Hazardous environmental condition
EVENT INVOLVES
Observed that 3rd Engineer unaware the presence of Petronas CIMMV.
EVENT LED TO
He is unaware of the Charterer instruction.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
The copy of Petronas CIMMV is not available in the ER control room. Same goe
SAC has discussed with him the content of the CIMMV. The soft copy of CIMMV
ACCOMPANYING PHOTO
Not Applicable
ence of Petronas CIMMV.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
in the ER control room. Same goes to Petronas HSEMS
e CIMMV. The soft copy of CIMMV and HSEMS is given to him.
EVENT INVOLVES
Observed that the CO has used correction pen to delete the entries in the roug
EVENT LED TO
Non conformance to various statutory requirement.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of vigour to follow regulation. 'Careless' attitude.
SAC has briefed the CO of his wrongdoing. He admitted that he forgot to follow
ACCOMPANYING PHOTO
Not Applicable
n to delete the entries in the rough deck logbook.
Cargo Damage
Property Damage
Pollution
ement.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
attitude.
admitted that he forgot to follow the standards.
EVENT INVOLVES
2nd Officer was not aware the presence of Petronas CIMMV on board. He could
EVENT LED TO
He is not aware the instruction given out by the Charterer.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of reading. The built-in culture for most malaysian.
SAC has performed one-to-one coaching with 2nd Officer wrt Petronas CIMMV
ACCOMPANYING PHOTO
Not Applicable
tronas CIMMV on board. He could not find the manual.
Cargo Damage
Property Damage
Pollution
he Charterer.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
malaysian.
2nd Officer wrt Petronas CIMMV.
EVENT INVOLVES
Observed that the Bosun was on top of the Crash Bar without safety harness w at starboard rescue zone. CO admitted that the PTW is not issued for the job be
EVENT LED TO
The Bosun may fall off. Non-conformance to the Company SMS.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
The Bosun did not communicate with the CO of the job planning.
SAC has discussed with the CO and both agreed to review the method of filling discussed with the Bosun.
ACCOMPANYING PHOTO
Not Applicable
rash Bar without safety harness while he is rigging the scrambling net on the support beam he PTW is not issued for the job because he is not aware of job.
Cargo Damage
Property Damage
Pollution
he Company SMS.
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
of the job planning.
ed to review the method of filling up PTW form and the issue raised by SAC will be
EVENT INVOLVES
Last Superintendent visit was on 23/12/2013 but the "vessel attending report" unknown.
EVENT LED TO
The Company SMS is not being followed.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
The superintendent maybe too busy with jobs in hand and forget to fill up the f
Advise the Master and C/O to remind the Superintendent to fill up the form.
ACCOMPANYING PHOTO
Not Applicable
but the "vessel attending report" not being filled up. The Management Visit date is
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
s in hand and forget to fill up the form.
erintendent to fill up the form.
EVENT INVOLVES
C/O and 2nd Off were unable to demonstrate the correct calculation of gyro er only 2nd Officer was actively make an entry by using on transit method.
EVENT LED TO
Company SMS instruction not being followed.
DIRECT CAUSES

HUMAN FACTORS
Fatique
Lack of knowledge
Lack of skill
Design Defense
Lack of knowledge and practice. The position of the gyro compass is on the Mo other tradition is that the CO perceived that the duty to calculate gyro error on
SAC has perform one-to-one exercise with both Officers. Proforma was also giv
ACCOMPANYING PHOTO
Not Applicable
the correct calculation of gyro error. The entries in the Gyro error book were minimal and y using on transit method.
Cargo Damage
Property Damage
Pollution
Lack of skill
Stress
Improper motivation
Lack of skill
Stress
Improper motivation
Training
of the gyro compass is on the Monkey Island is also become a reason of not doing it. The he duty to calculate gyro error only falls to 2nd Officer.
th Officers. Proforma was also given to them.

SAC Report TG Huma 9 Jan 2014

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SAC Report TG Huma 9 Jan 2014

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No.

Date of Birth Nationality

Expiry Date of Passport

Guidelines during adverse weather

SMS Incident Notificationand Reporting

JSA, IPO and Toolbox HSSE Walkabout

PTW System Introduction to OVID

DECISION MAKING SKILL

ACCIDENT/INCIDENT REPORTING SKILL

RECORD KEEPING SKILL

Not applicable FAIR AVERAGE

defuse any crisis built up during operation. A few packs of cigarrette

levant instruction in the CIMMV have been shown.

DECISION MAKING SKILL

Additional Comments: He is dependent to the Master.

ACCIDENT/INCIDENT REPORTING SKILL

Additional Comments: He is dependent to the Master.

RECORD KEEPING SKILL

Not applicable FAIR AVERAGE

o the Master and cannot be a good example to 2nd Officer.

Personnel Injury Delay/Offhire

Vessel Damage Company Reputation

Equipment Damage Impaired Performance

DESCRIPTION OF THE CONSEQUENCES

INDIRECT CAUSES (PRECONDITIONS)

ROOT CAUSES (LATENT FAILURES)

Lack of inspection regime.

CORRECTIVE ACTION TAKEN

SAC has advised the Master to generate Drydock Defect List.

amaged at its centre.

Equipment Damage Impaired Performance

and the risk of loss of anchor is evident.

Inadequate Engineering Inadequate tool or equipment

Inadequate Purchasing Inadequate work standards

Communication Incompatible goals

Organization Error enforcing conditions

ock Defect List.

Personnel Injury Delay/Offhire

Vessel Damage Company Reputation

Equipment Damage Impaired Performance

DESCRIPTION OF THE CONSEQUENCES

INDIRECT CAUSES (PRECONDITIONS)

ROOT CAUSES (LATENT FAILURES)

CORRECTIVE ACTION TAKEN

The Master has already informed the Superintendent.

the air due to major leakage.

Equipment Damage Impaired Performance

pefully the charterer did see this.

Inadequate Engineering Inadequate tool or equipment

Inadequate Purchasing Inadequate work standards

Communication Incompatible goals

Organization Error enforcing conditions

Personnel Injury Delay/Offhire

Vessel Damage Company Reputation

Equipment Damage Impaired Performance

DESCRIPTION OF THE CONSEQUENCES

Non-conformance to the watchkeeping standards.

INDIRECT CAUSES (PRECONDITIONS)

ROOT CAUSES (LATENT FAILURES)

Lack of interest to improve work standards.

CORRECTIVE ACTION TAKEN

t his signature in the ER Logbook since 12/01/2014 until the 14/01/2014.

Equipment Damage Impaired Performance