LEARNING FROM INCIDENTS

FACILITATOR GUIDE

FACILITATOR GUIDE: ‘Personnel Transfer’

PART A – OVERVIEW ON PERSONNEL TRANSFER

▪ INTRODUCTION
▪ ABOUT PERSONNEL TRANSFER
▪ KEY LESSONS
▪ WHAT CAN YOU DO?

PART B – RUNNING THE PERSONNEL TRANSFER SESSION

▪ VIDEO DESCRIPTION
▪ DICUSSION POINTS
LEARNING FROM INCIDENTS
FACILITATOR GUIDE

PART A – OVERVIEW ON PERSONNEL TRANSFER

Key lessons
Introduction
Key lessons
The aim of this learning session is not only about watching a video,
it is to think about and discuss risks associated with PERSONNEL ▪ Participants should understand
TRANSFERS as a group. We want the audience to reflect on the the risks associated with
requirement of undertaking personnel transfers and means to personnel transfer mechanisms.
▪ Do not undertake personnel
either eliminate transfers or improve the risk management transfers unless it is absolutely
processes around this activity. During this session the group will necessary. This eliminates the risk
have an opportunity to elaborate on how to prevent incidents (see the ‘Hierarchy of Controls’ in
from happening at their sites in the future. the slide pack).
▪ When undertaking personnel
Plan to introduce the session, show each video and have group transfers ensure company
procedures such as risk
discussions; then conclude using information from this guide. Take assessments, permit to work,
5 minutes at the end for everyone to write down their personal assessment of equipment
action commitment. Share actions as a way to help each other condition etc. are complied with.
If in doubt, STOP WORK and seek
complete them.
guidance.
About Personnel Transfers
What can you do?
Personnel transfer is a high-risk activity which, over the years, has
become a routine operation in the maritime industry. It is ▪ Demonstrate your chronic unease
out in the field – don‘t rely on
estimated that about 150,000 personnel transfers take place norms (what has become normal)
within Shell’s Downstream Trading Operations alone, annually. and do not hesitate to challenge,
respectfully.
There are various mechanisms for personnel transfer ranging from ▪ Engage with those planning the
use of an accommodation ladder when a vessel is alongside a activity – ask ‘do we need to
terminal, to basket transfers offshore using a vessel or platform undertake this personnel transfer
cranes that qualify as complex lifts. or is there a better alternative?’
▪ Undertake necessary personnel
While mostly personnel transfers are undertaken using stringent transfers safely – what controls
controls, previous incidents indicate that in a number of cases, are in place to reduce the risks
and am I complying with the
these were not as effectively implemented. Unfortunately, if appropriate company
something goes wrong with personnel transfer activity, the procedures? The company
likelihood of a person falling in the water, suffering a major injury, procedures are the minimum
or worse, is extremely high. standard, ask, do I need
something extra in this instance?
Eliminating unnecessary personnel transfers, implementing, and ▪ Ensure personnel transfer
equipment is safe – has all the
improving risk mitigation measures can help us prevent such
equipment associated with the
incidents from happening. So, keep prompting the team with the transfer been inspected and
thought – was the transfer really necessary, or could something maintained to industry and OEM
else have been done? standards, and can you prove it?
▪ Welcome STOP WORK – ask, what
do you not want to tell me? Then
respond appropriately. Make is
safe for people to speak up.

ELIMINATE (where possible)

and IMPROVE risk
management of maritime
personnel transfers within
your organisation.
LEARNING FROM INCIDENTS
FACILITATOR GUIDE

PART B – RUNNING THE PERSONNEL TRANSFER SESSION

Video Description

These scenes were constructed with actors in a staged location (not a real situation). The vessels had
been made hydrocarbon free and there was gas testing before any non-intrinsically safe items were
taken onboard (mobile telephones, camera equipment etc.). When discussing these scenarios, get your
team to highlight the safety flaws. Different industries, regions and companies all have different rules.
Therefore, encourage your team to think about what safety precautions apply on your current vessel.
Here are two lists of things missing or deliberately done poorly in the videos. How many did your team
spot?
Universal examples of safety precautions missing in the videos (that should apply to everyone):
✓ not using a mobile phone (or other non-intrinsically safe device) on deck;
✓ keeping hands free during personnel transfer;
✓ sufficient manning on all vessels;
✓ supervision during critical work (both at the tankers and the launch);
✓ toolbox talks before start of work;
✓ use of job hazard analysis prior to the start of non-routine work (e.g. use of baskets instead of
combination ladder in Video 3);
✓ securing the pilot ladder to the ship’s hull as per SOLAS requirements;
✓ not carrying anything or using a backpack when climbing a pilot ladder;
✓ taking time to do work properly (do not rush);
✓ use of gangways when transferring between vessels;
✓ eliminating the need for transfer at sea where possible; maintaining effective 3-point contact
when climbing up and down ladders; fatigue management.
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Company specific examples of safety precautions missing in the videos (try to spot the ones that apply
to your company):
✓ wearing fire-retardant overalls with long sleeves pulled down to the wrist;
✓ wearing uniform to identify yourself;
✓ wearing chin straps on helmets;
✓ use of self-righting lifejackets with crotch straps;
✓ use of gloves for different types of work (including climbing the pilot ladder or basket transfers);
✓ allowable type of baskets (rigid versus collapsible);
✓ crane certifications and risk assessments; training or briefings prior to personnel transfer;
✓ briefings for first time transfers;
✓ communication requirements between launch and vessel during transfers.

Discussion Starters

Discussion Points
Questions after 1st Scenario
What factors led to this incident?
These items are to help you to have a great discussion. Don’t show What personnel transfer related
them to the participants, but ask questions to find the answers. incidents or events have you
experienced that could have been
Scenario 1 prevented?
1) What factors led to the incident? What other methods could have been
used instead of this transfer?
• Direct causes
o Decision to do the personnel transfer instead of waiting Questions after 2nd Scenario
until the ship was at the dock What behaviours contributed to this
o Pilot ladder not secured to the ship hull, which led to the incident?
swinging of the pilot ladder and technician losing What interventions could have been
balance taken and when?
How could this incident be avoided?
o Backpack making technician unstable and impeding life
jacket/vest Questions after 3rd Scenario
o Pilot ladder in disrepair / not fully inspected What went wrong here?
• Indirect causes Why did it go wrong?
o Lack of training and familiarisation What alternative methods can we use
o Wheelman on launch did not intervene when he asked instead?
if the technician had seen the video
Think about to Finish
o No toolbox talk or risk assessment done prior to the
The importance of feeling able to
transfer speak up
2) What personnel transfer related incidents or events have you The importance of feeling able to
experienced that could have been prevented? intervene when things are unsafe
• Gangway wire damage – Gangway fallen off – Gangway design The impact of how leaders have
issues - some of the Gangway greasing points difficult to access responded in the past
and remain neglected The impact of the context, or
situation, on safety
• Personnel on the pilot ladder hit by moving boat
How has this reflective learning
• Swing rope incidents changed what you will do next time
you want to bring someone aboard?
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3) What other methods could have been used instead of this transfer?
• For this case, technician could have boarded when the vessel was alongside
• Replace pilot ladder with mechanical pilot hoist with redundancy, and onboard personal launch
• Install heave compensated platform
4) What are your other observations?
• Lack of additional personnel on launch to assist in recover of MOB
• Pilot ladder is too low (in the water)
• Pilot ladder not secured to the accommodation per regulations
• Accommodation ladder not secured to the vessel hull
• Gangway not secured to the vessel hull – not in line with SOLAS requirements
• Commercial pressure to get the technician onboard during the passage
• The hierarchy of controls to manage the risk was not followed
• Unplanned work – it seems like the rigging of combination ladder was not planned and was an
unplanned work and there was no toolbox talk or risk assessment
• Rigging of combination ladder is a critical activity and should be supervised
• Poor supervision - Master using phone on the bridge
• Personal launch - no crew on deck to assist technician
• Poor condition of ladder identified by the AB, but no intervention made (dares not speak up due
to poor atmosphere and working relationships)
• ABs working near ship side without railings without using life jacket/vest, and fall protector
devices
• Seems like Technician did not have any training for, or familiarization of, the task
• No communication between the launch and tanker on readiness of the transfer
• ABs without direct communication to the bridge
• Technician climbing with backpack which does not help with balance and may prevent proper
operation of the life jacket/vest.

Scenario 2
1) What behaviours contributed to the incident?
• Commercial pressure to leave the berth
• Poor planning - no gangway plank rigged and ready for use
• Rushing to get the job done
• Risk normalisation and/or complacency – I have done before so it will be OK
• Tanker man ignored intervention by deck crew
• The crew seemed to have missed lunch, looked fatigued (yawning) and was distracted by the
phone prior to his transfer
• Master antagonistic (hostile)
2) What interventions could have been taken and when?
• Intervention: Reminding the Master to give enough time to get the man off and not to rush.
When: When the Master asked to leave the berth
• Intervention: Reminding not to jump across the wide gap. When: When walking on the side to
leave the vessel, or better at a toolbox talk long before this
• Intervention: Reminding to wear a hardhat. This would have given a sense that safety is
important and might have altered people’s attitudes. When: Early in the day
• Intervention: Reminding tankerman not to use phone on barge. When: before it is used
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3) How could this incident be avoided?

• Not allowing jumping across to the gap – ship to ship or ship to shore
• If above is not achievable:
i. Vessel crew to be present on both sides to assist in the transfer
ii. Adequate mooring system to prevent the “sway” motion of the vessel
iii. Objective controls to limit the maximum gap across which the personnel can jump across
4) Other observations
• Barges starting to pull away from each other – meaning lines hadn’t been tended properly
or tow was already moving before tankerman had departed

Scenario 3
1) What went wrong?
• Tagline got stuck on the launch side and became taut. This gave a jerk to the basket and
consequently Chief Engineer lost his balance and fell in the water
• Chief Engineer was carrying his bag, and this may have caused his grip on the basket to be less
secure
2) Why did it go wrong?
• A culture where people’s safety isn’t the top priority – poor leadership not setting this as a
priority
• Poor systems and procedures to allow this transfer to be done in this way
• Lack of supervision
• No deck hand on launch side to tend the line and give signals to the tanker’s banksman
• Bosun hasn’t done basket transfer with person before and doesn’t have experienced support
• No paperwork/inspection documents for the basket
• Wrong knot used to tie tagline to basket
• Chief Engineer carrying bag on his shoulders. The bag could have been transferred using heaving
line, cargo net etc.
3) What alternative method can be used instead?
• Frog is a safer means than the basket
• Talk about what barriers are in place in your company and what alternatives you have available
to you
4) Other observations
• Starboard accommodation ladder, not working. The Master did not prefer the port side as he
wanted to give a good lee. The lee should not be a big concern in the channel, so the vessel
could have used port side accommodation ladder. A risk assessment of using port side versus
doing the basket transfer could have been done
• Basket and crane do not seem to be certified or maintained
• No pre-transfer briefing for the Chief Engineer
• The work is not the routine method of personnel transfer, but no toolbox talk or risk assessment
was done
• Risk normalisation – the residual risk of lifting and hoisting the basket was considered to be the
same as that of cargo handling
• The crane hook safety latch was tied open with string
• Banksman were not wearing a hi-vis (high-visibility) jacket
• No test run for the basket transfer. Testing first is a highly recommended practice
• Both ships are undermanned compared to normal. There is no banksman on the launch and no
one to handle taglines.
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To Finish
At the close of the engagement, discuss:
• The importance of feeling able to speak up and whether people feel they can
o Would you have been able to intervene in these scenarios?
o How would you have done it?
o What would you have said?
• The importance of feeling able to intervene when things are unsafe and what happens when
someone does (shouted at, rewarded or ignored)
• The impact of how leaders have responded in the past (good or bad)
• The impact of the context, or situation, on safety, such as:
o the weather
o if the vessel leaders are approachable
o if you feel supported by the onshore staff
o If you socialize on your vessel or if everyone stays in their cabin
o if you get news from home that is on your mind (good or bad)
• How has this reflective learning changed what you will do next time you want to bring someone
aboard?
o Does your company have a Launch policy?
o What is it?
o Does it require more than one person regardless of size?
o Are there other requirements for launches and personnel transfer?
o What are they?
o If you spot any missing, what do you do?