Podcast
Questions and Answers
What was the initial observation made during the lifting operations?
What was the initial observation made during the lifting operations?
What failure in procedure contributed to the errors during the operation?
What failure in procedure contributed to the errors during the operation?
What equipment was involved in the incident during the lifting operations?
What equipment was involved in the incident during the lifting operations?
What was identified as a physical issue with the hydraulic release shackles involved?
What was identified as a physical issue with the hydraulic release shackles involved?
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What critical process was bypassed when changes were made to the lifting operation?
What critical process was bypassed when changes were made to the lifting operation?
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Flashcards
Hydraulic Release Shackle (HRS)
Hydraulic Release Shackle (HRS)
A device used in lifting operations that can release under hydraulic pressure.
Spontaneous Opening
Spontaneous Opening
Uncontrolled opening of the HRS without external trigger, causing safety hazards.
Complacency in Safety
Complacency in Safety
Making assumptions or decisions without following safety protocols and checks.
Management of Change Process
Management of Change Process
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Risk Assessment
Risk Assessment
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Study Notes
Hydraulic Release Shackle (HRS) Failure
- A hydraulic release shackle (HRS) pin opened unexpectedly during lifting operations on a vessel.
- The blue-colored HRS, connected to lifting slings, opened and fell approximately 4-5 meters.
- No one was injured.
- The HRS was hanging from a hydraulic hose after the incident.
Cause Analysis
- Complacency: Assumptions were made without full compliance to manufacturer, company, or safety procedures.
- Improper Change Management: The way the job was done changed without proper documentation or approval.
- Lack of Procedures: Vessel crane hydraulic power unit (HPU) procedures and manufacturer guidelines might not have been adhered to.
- Insufficient Risk Assessments: No operational or task risk assessments were performed.
- Gaps in Communication: Communication between involved parties was less than optimal.
- Additional Issue: The yellow-colored HRS was also damaged.
Lessons Learned
- Remain Curious: Question potential risks and their mitigation.
- Effective Communication: Clear, effective communication is crucial.
- Thorough Risk Assessment: Rigorous risk and task assessments are essential.
- Adherence to Procedures: Compliance with procedures and manufacturer recommendations is mandatory.
- Change Management: Formal change management procedures should be part of any alteration to work plans.
Actions Recommended
- Equipment Safety: All equipment modifications must align with the manufacturer's instructions.
- Review Procedures: Existing protocols for equipment should be reviewed and updated if necessary.
- General Review: An overall review of similar equipment used on other projects is advisable.
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