Safe work instructions

Patrick Terminals’ safe work instructions for lashing/unlashing did not specifically cover the recognised safe practices of not working under containers or between moving containers and fixed objects. Consequently, there was a discontinuity between the level of awareness regarding these dangers and the training new employees received during their induction period.

Hazard assessment process

Patrick Terminals’ hazard identification process had not identified the dangers of working near or under containers being loaded.

Risk assessment process

Patrick Terminals’ risk assessment process for lashing and unlashing operations had not anticipated a fatal accident resulting from being struck by items falling from a portainer or cargo, or from being struck by a moving container. As a result, while the appropriate risk control for this occurrence had been covered during employee training, this was not reinforced in safe work instructions, an important risk control measure.

Safety zone guidance

Patrick Terminals had no formalised policy in place to provide clear guidance to its stevedoring employees about where they could or could not work on a ship when cargo was being loaded or discharged.

Terminal safety management

The implementation of Patrick Terminal’s safety management system resulted in an environment where Patrick Terminal management and stevedores were disconnected in relation to the management of some of the day-to-day workplace safety risks. As a result, there was little ownership of the safe work instructions by the stevedores, and some of the more experienced stevedores were probably no longer aware of the risks posed to them when they undertook unsafe ‘workarounds’ in the workplace and these were not identified by Patrick management.

Safety issues not covered in guides for operators

The recognised safe practices of not working under or near a container being loaded is not well reflected in national and international guidance published to assist container terminal operators develop their own safety policies and guidelines.

Risk-event reporting

The culture which existed in the Patrick terminal did not encourage the reporting of non-compliances or unsafe acts. Consequently, two critical parts of an effective safety system, which had a direct impact upon its ability to effectively manage safety in the terminal, the ‘reporting’ culture and the ‘just’ culture, were either not present or were misunderstood in Patrick’s safety system.