The crew did not use resource management principles to ensure that they had a shared mental model of the task that they were carrying out. As a result there was confusion amongst the various crew members as to their roles and responsibilities at the time of the incident
Action taken by BP
The ATSB has been advised that the BP Shipping Control of Work (CoW) procedure requires Tool Box Talks (TBT) to be carried out before any job is carried out. The CoW system is audited regularly by the vessel Shipboard Management Team and BP Shipping’s own internal auditors.
This is however only a snapshot. The TBT was incomplete on this occasion. Staff have been reminded of their obligations under the BP Shipping CoW system and the consequences of incomplete TBT’s have been highlighted in Fleet Safety Training Officers visits and the sea staff briefings being conducted after this incident. The BP Shipping CoW system is being reviewed and updated. The requirement to carry out good quality TBT’s will be emphasised and tools will be provided to the Fleet to enable them to carry out better quality TBT’s. The review will be complete by the end of 2011 and guidance will have been issued then.
The ATSB is satisfied that the action taken by BP Shipping adequately addresses the safety issue