Injury

Corrective/Preventive Action follow up (rolling document)

ItemDateTime Of IncidentRelated toEquipment (if applicable)Contarctor CO.Corrective ActionStatus (open/closed)SYNERGY NO.Shift MangerTypeNumberInj/LTIEstimated/Actual Lost DaysCase Explanation Root Cause (As per preliminary investigation findings)Employee statement summaryPreliminary Investigation ByRisk ValueActionOwner-shipDeadline1January 15, 201314:30Gate1st aid case (HIPO)please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient During the inspection process of a IMO container in the inspection area, 3 stevedores from TRADEMAR Co inhaled excessive quantities of vapor (Leather Glue) and were transferred to SCCT clinic suffering from breathing difficulties. Two were treated for first aid at the SCCT clinic with oxygen/fresh air and released. The 3rd worker, (Mohamed Abd ELfatah Ibrahim ID 6422), because he had chronic sinusitis, was transferred by SCCT ambulance to Port Fouad General Hospital for more advance treatment, direct oxygen therapy. He was later released and declared healthy.Immediate causes

Involved person inhale excessive quantities of vapor (Leather Glue)

Underline causes

1-Heavy duty workload.2-Lack of supervision.3-Process change .Root Cause

1-Lack of awareness regarding IMO containers during handling and inspections in the customs inspection area. 2-SOP didnt cover IMO handling precautions .Mohamed Abd ELfatah Ibrahim ID: 6422

Department: OPS Outsource(Tradmar Co) Position: stevedore worker Experience: 5 yearsWhile discharging subjected container content for customs inspection process we smell bad odor which makes us feel faint .- How workers were inside container ?Two + me - Did you know whats cargo content?Adhesive material.- Before you start working, did you attend TBT?Yes ,I did.- Did you open this Unit for ventilation before start discharging?Yes we open it & left open for 1 hour before discharging its content.- Did you inform your Supervisor about abnormal smell ?No.- Why?It was normal but when we reach the end of the container & remove the carton from bottom the odor start and suddenly we faint.- From your opinion how can we avoid this incident ?make rotation for worker each 15 min ,leave container and stay in open air for 10 min.Operations: Mohanad Rehan Engineering: Mahmoud Dorman HSE: Mustafa Fathy1 1 = 1Prepare MSDS training for gate service supervisorsPrepare training for gate service supervisor & subcontractor supervisor to raise their knowledge about dealing with IMO container.Gate dept. to provide chemical set of PPE (Gloves, full mask) for IMO cargo inspectionGate to Modify IMO cargo inspection SOPExclude stevedore workers whom have any medical history related to breathing difficulties or allergy from IMO cargo handlingHSEHSEGateGate /HSEGate01/02/201301/02/201315/02/201310/02/201301/02/2013New2January 31, 20136:40OPS Blue1st aid case (HIPO)please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient While lashing M/V UASC KHOR FAKKAN and one from our lashing team suffered from falling of long bar (3rd tier ) directly to his right foot while tighten it .Immediate Cause:The leg of a ENG Technician trapped between the spreader & the spreader support of low bed trailer.Underlying cause: Organization Cause.1. Inadequate SOP for this job.(using generic SOP)2. Work pressure 3. Poor decision making4. Poor communication between work team.Root cause:People CauseOperating / Controlling the panel by unauthorized person . Name: Abd Elfatah Gomaa Abd ELfatah ID: 6416

Department: OPS out source \Tradmar Position: Lashing worker Experience: 3 years After my colleague Mohamed Reda fix the hook of vertical 3rd tier lashing bar ,I bring the turn buckles to start lock it ,after I connect it and while tighten I surprised by bar falling directly on my feet .-What was the distance between you & the containers row?About 30 cm-What was the position of your both hands when bar falling?I use my both hand for tighten the turn buckles using short momentum bar -Did you check the position (status )of the bar hook before start tighten ?No, as there is no indication for this type.-from your opinion ,Why this bar fall down ?While tighten ,the bar hook get out from corner cast.Ahmed HegazyAhmed OsmanMustafa FathyProp. 2 Sever 1 = 2OPS Lashing to modify vertical bar handling SOP to be 2 people exit while tighten this kind of lashing bar in 1st row of sea & land side then publish this for all lashers OPSFebruary 10, 2013New34February 28, 20130:00OPS OrangeInjury case (LTI)10please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient one of lash staff was working on M/V Ras Sedr and he started to dismantle one of the zargena and lash bar. When he was knocking on the zargena by using hand tool (as shown in the attached photo), something injured his left eye.Organization cause :1. Inadequate safety control.2. Inadequate risk assessment.Involved Person: Name: Mahmoud Mohamed Abo El-Enean ID: 6389 Department: OPS Position: Lash (INMAR) Experience: One year

I started to dismantle the first zargena and lash bar on M/V RAS SEDR but I cant dismantle the zargena with my hand so that I tried to knock on the zargena by using hand tool.When I was knocking on the zargena, Something injured my left eye.

1- Did you wear safety glass?- No, we dont receive safety glasses.2- Did you have any instructions that you must wear safety glass?- No, I didnt have any instructions.Operations: Mohamed Adel Engineering: Amr Shorbagy HSE: Mohamed El-TabeeyPossible 3 * Minor 2= 6Preventive measures and improved procedures: Review and update the lashing SOPs. Update the lashing R.A . on vessels by adding eye injury hazards during dismantling short / long bars. Look as alternative hand tools to be used. Provide safety glasses to all lasher workers on vessels. (Still under review by OPS) Corrective actions: Add this case to TBT and highlight that all lasher workers on vessels must wear safety glass during working on vessel to prevent eye injury. (Still under review by OPS) Lash supervisors must check lashing PPEs during safety talk.OPS04/03/201304/03/201305/3/201301/03/201305/03/2013

5June 17, 201318:00OPS OrangeInjury case (LTI)Trade MarWhen Lash worker (Trade Mar) was walking on catwalk of M/V INTEPENDENT VENTURE (Berth 01) to close twist lock sea side, the catwalk fall down and the lasher also fall down (1.5 meter distance).K14Immediate causes The dual man fall down during working on M/V INTEPENDENT VENTURE.

Underline causes When the dual man was walking on catwalk, the catwalk fall down.

Root Cause Organization Cause :- Negligence 3rd party.

Technology Cause :- Excessive wear and tear of tools (the catwalk rusted and defected).Injured Person: Name: Hassan Mohamed Attea ID: 6106 Department: OPS Position: Lasher (dual man) Experience: 9 years

- I was working on M/V INTEPENDENT VENTURE in berth 01.- I had work in bay 01 to close twist lock in row 01 sea side.- When I was walking on the catwalk in bay 01 sea side to close the twist lock, The catwalk fall down and I also fall down (approximately 1.5 meter distance) on my right foot then my colleague called the supervisor and they transferred me to clinic.

1- There was working in this bay before?- No.2- Did you notice problems in catwalks before during working?- Yes I noticed.3- What you did in these cases?- I inform my supervisor.Operations: Adel Khedr Engineering: Ahmed Shawky HSE: Mohamed El-TabeeyRare (1) * Severity (3) = 31. Check the proper way to protect SCCT employees and reserve SCCT rights in similar cases.2- Review the vessel inspection procedure to guarantee informing the owner of the vessel also when unsafe and defects are found - this to be part of the inspection report document.

3. Add this case to TBT and highlight thatLash team must make visual inspection for catwalks in bays before working then they must inform the lash Forman of the vessel.SCCT ClaimsHSSE

OPS

09/07/201310/07/2013

22/06/2013

NewHatem Hosney

7August 23, 201310:55ENG -DSpreaderSQ 13Injury case (LTI)/One of Eng Technicians had been injured in his left instep while he was working to change the spreader of QC 02, his left leg trapped between the spreader & the spreader support of low bed trailer causing a fracture in his toes & rive wound .Immediate cause:- The leg of an mechanical technician trapped between the head block & the spreader support of low bed trailer.Underlying causes :Organization Cause.1. Inadequate SOP for this job.(using generic SOP)2. Work pressure 3. Poor decision making4. Poor communication between work team.Root Cause:People CauseOperating / Controlling the panel by unauthorized person Injured Person: Name: Hussin Elgendy ID: 1208

Department: Eng Position: Mechanical technician Experience : What happen?Why he hoisted up and get down again without confirmation with us.

Then he was suffering from his pain. Witness: Name: Mohamed Ibrahim Elmewafy.

ID: 232 Experience : 7 years.

Department: Eng. Position: Mechanical tech.

We were changing spreader of QC 02 and after dismantle the old one with new one and while lowering crane Head Block, I was myself and the injured person on top of the spreader and vessel supervisor with us, he asked to help us from control panel, then he landed the Head Block on new spreader and raised it again, we surprised by this sudden move, asked for STOP STOP, then we hear a high voice of the injured person. How many persons were in this task ?- There were only 3 persons. (2 from Eng. Dept in land to change the spreader + 1 in E- Room to activate the Bypass ). In similar cases, did you know the required number of workers whom should handle this process?- Sometimes 2 or 3 persons. According to what, this number decided?According to the tasks & duties we have. Who was controlling the panel during this process?- Vessel SV, was controlling from the panel as per his request. Who is the responsible of controlling this panel?- Engineering. Why he controlled the panel instead of the designated person?- As I mentioned before, this due to his request, also we were only two persons. How did you noticed the victim got injured ?- While the vessel SV hoisting up I heard him saying why he is hoisting up then he shout lower lower the spreader. Why did OPS SV hoist up ?- I didnt know why he make this hoist up, but after the accident I informed that a wire slack, so he decided to hoist up to avoid any wire damage. Where was your colleague position ?- He was stepped on 2nd or 3rd step of spreader ladder (left side), not sure because I was busy with my side.(right side). What is your opinion to avoid reoccurrence of similar cases ? - All OPS supervisors should be trained how to safely operate control panels. Who was the leader of this job?Me. How can you communicate with the others, was it by UHF radio, verbal or hand signals?- Was verbal, because the distance was very narrow. Did anything affected the communication?- No, but we have many duties before this task & we also received many calls for brake down after this task. Does that duties affect your concentration on this job ?- No. Was the Truck moved during spreader replacement ?- No. What do you think went wrong ?- I think his foot stepped on the wrong position, If I were in his place the same situation will happen to me.- Wrong action from Ops SV.Witness: Name: Mohamed Seif El eslam ID: 6-7 Years.

Department: Ops. Position: D&W controller.It was during my handover and there were 2 from Eng. Team one in the right and one on the left, and while hoisting down a slack happened to the wire Mr. Hamza SV started to hoist up suddenly I heard people are shouting to lower the spreader then we found him in this situation can not step on his foot then, we ask the ambulance.

Where was your position at the time of incident ?- In front of checker cabin. Did you noticed the injured person position at that time ?- Yes, he was hanged on the spreader & one side was attached the spreader to Head Block (left side ) and the other was not. Have you ever changed the spreader with eng. Team before ?- Yes, there was one tech. has come for spreader replacement in night shift. Are you trained about controlling this panel?- No. Do you think what went wrong ?- No clear message delivered to all sides to confirm hoisting up or down.Witness: Name: Mohamed Hamza Ahmed ID: 1463

Department: Ops. Position: Vessel Supervisor ( Acting ). Experience : 5 years ( Only two months acting ). I was helping Eng. Team for spreader replacement, I made hoist up during spreader replacement as there was a slack then I heard somebody shouting lower the spreader, then I stopped.

What was your position at that time ?- I was controlling wire from control panel. From your position, could you notice the two persons?In the beginning I was noticed both, then I noticed only one ( The right side technicians). Who was the leader of this task?Mewafy ( Right side technician). Did you have a proper way of communication during this process ?- Yes, with Mewafy. Did you have the same communication with both technician ?- I was only looking at Mewafy (right-side tech.) What was the purpose of hoisting up?- I was only withdrawing the slack, I didnt mean to hoist up the spreader. Are you trained for similar cases ?- No. Did you made this task before?- Yes, several times. You as a supervisor, did you think that this behave is right or not?- Wrong, but I need to give the assistance to Eng team. Khaled Hegazy Moataz Hewalla /Amr Elshorbagy Hisham Ismail / Mohamed Abass.Unlikely (2) * Severity ( 4) = 8 1 Engineering department to write the adequate SOP for this job & to be sent to HSE department to be approved for the concerned safety parts.

2 A- Engineering team to prepare the Risk assessment for this task & to be communicated with HSE department for reviewing it B- To review all routine / non routine jobs risk assessments which located in Eng library.3 To add this accident in the Tool Box Talk & to highlight to operations team that no one is allowed to operate any equipments without authorization.

4 To share this accident via all notice boards

1-Eng2-Eng / HSE3-Ops / Eng4-HSE / HR relations

25/08/2013A- 25/08/2013B- 15/09/201301/09/201326/08/2013

NewHany Mustafa8August 26, 20139:30OPS RedTR 50 & RS 05 Injury case (LTI)CampbellTR 50 hit YSV Sherif Abd El Shafy ID:1125While the was directing on the back reach to deal with RS 05 operator. Immediate causes TR 50 hit YSV While the was directing on the back reach to deal with RS 05 operatorUnderline causes 1-YSV Didnt follow pedestrians crossing lines (Zebra lines)2-TR Driver was trying to avoid vibrations from defected manhole .

Root Cause 1-SCCT didnt receive any complain regarding defect in manholes .(no reporting)2-TR driver wrong attitude .3-Defected manhole concrete frame Involved Person: Name: Mohamed Ali Hassan ID: 1062

Department: OPS (Campbell) Position: TR driver Experience: 2.5 years

I was in the WS with TR 50 because there were a problem in the screen and the TR wasnt accelerate , so they fixed only the screen and they asked me if I could drive with the speed problem, I said no problems , so I directed to my location at 04E lower for loading a container, then I reached to the Quay side and took the main drive way to direct to QC 17, There were a barriers in my right side (PJ working area for replacing the gutter covers), and there were a PU in the lift of the way ( Mike) and there were another TR in the opposite direction. Then after I passed the barriers, I found a covered manhole which located in the main drive way so I deviate with my TR to be in the waiting lane (after the back reach) to avoid the passing on it because the resulted vibration cause a pain on my back. And in my sight I saw a RS was stopped in the back reach and there were two persons was stand on it and while I pass beside the RS 05 I felt that something stopped me and found a radio device & helmet was flying from outside into my cabin, then I found that I crashed the YSV.

1- What is this day in your shift?- It was the second day shift.2- What was your working hour in the rotation in the time of the accident?- I was working in my 2nd Hr in my rotation.3- Did you see the person who you crashed in the accident moment?- No, I didnt see him because I didnt concentrate with him.4- What was the last scene you saw the injured person before you crashed him?- He was standing beside the RS and his back was toward me.5- Was he standing on the RS or the ground?- I dont remember because I didnt concentrate with him.6- Do you have anything else you want to add?- The hit was there fault because the standing persons on the ground didnt have fixed position so the probability of crash is high & he was in a blind point for me.- The causes of such accidents was from the PU s drivers as they didnt stop on the stop signs and things like that.

Wetness: Name: Waleed Mansor Hessen ID: 3626

Department: Ops outsource (Sinai) Position: TR driver Experience: 2 years. I was working under QC 11 in my TR at lane 2 and my sight was toward the accident directly. I saw that the YSV was standing on the RS stairs, then he fall down from the stairs and roll over on the ground, and there was a TR coming in opposite direction so his leg came under the TR.

1- What was your working hour in the rotation in the time of the accident?- I was working in the 3rd Hr in my rotation.2- Where was you position in the time of the accident?- I was under QC 11 on lane 23- Were there anybody see the accident with you?- The wharf of QC 11 saw him after he fall.4- Was there any time interval between your vision of the YSV when he stand on the RS stairs & the accident scene?- No, I was seeing the whole event.

Wetness: Name: Mohamed Abd El Raoof Ahmed Shoeeb ID: 319

Department: Ops Position: RS Operator Experience: 2 years. 1- What is the reason of being in the accident location?- The YSV Sherif asked me to go to berth 05 to handle twin containers on a defect TR.2- Was there a conversation happened between you and YSV sherif?- He left his PU in the Mik and walk to the back reach then I stopped and I waved to him to come beside and in his way the TR hit him.3- In which part of the TR, it hit the YSV?- From the TR head right side. 4- Was sherif in a blind position to the TR driver?- No, he wasnt.5- Was there a sun beams disturbed you?- No, either to the TR driver.6- Where was the position of the YSV sherif in the time of the accident?- Between the back reach and the waiting lane.7- Was TR 50 drove fast?- He was speedy but I cant determine his speed.8- Where did TR 50 stop after it hit the YSV?- He stopped after the YSV reached to the middle of the trailer.9- What was the distance between your RS and the TR when it hit the YSV?- About a width of a container (2.5 m)10- How do you think this incident could be avoided in future?- The TR drivers must be more careful and stuck with the safety instructionsOperations: Amr Rashwan Engineering: Sayed Abo El Eneen HSE: Mohamed Abd El Rahman + Ramzy Maher possioble (3) * Severity ( 4) = 121 Install Megaphone in all Yard SV PUs or provide Radio device for all RS & EH equipment 2 TBT for all TR drivers to report any abnormalities to their Direct SV.3 PUT Plan for PM for manholes survey and required repair 4 OPS to review RA for Yard SV activities addressing safe zones for YSV and revised SOP5 TR Driver is not allowed to drive inside terminal anymore 1-Under study2-10/09/2013OPSOPSENG TSOPSHR/OPSAmr Rashwan

9September 3, 201313:30OPS RedN/AInjury case (LTI)InmarDuring lasher was dismantling a short lash bar from the 3rd tier cat walk and while he get it down it hit his left hand in the top hand rail of the cat walk.People- Lack of attention of the lasherName: Ahmed Monaem Elgamal ID: 6315

Department: OPS ( Inmar Contractor ) Position: Lasher Experience: 1 year , 3 months

I was dismantling a short lash bar from the 3rd tier cat walk and while I get it down it hit my left hand in the top hand rail of the cat walk.

1- What was your working hour in the time of the accident?- That was the first hour after taken 45 min. as a rest .2- Did you feel fatigue ?- No , I didnt and last night I slept about 7.5 hours .3- Did you trained about the safe practice of dismantling the lash bars?- Yes, and it was one handunder the bar and the other hand catch it, and I used this instructions while working.4- So what was happening causing this incident?- I dont know.5- Did you work alone in the same cat walk ?- No , there was another lasher with me but he worked away from me by two containers distance .6- Was the short bar heavy for your hand ?- No , this lash bar was short bar and can carry by one person .7- Did you use extreme effort for dismantle the lash bar ? - No , I didnt .8- Did you face any problem while dismantling the bar ?- Yes , it take a long time to dismantle the lash bar , it was stuck . 9- Did you have a historical injury in your hand ?- No , I didnt .10- Were you harry ?- No , I am werent 11- Do you wear PPE ?- Yes , but the gloves used is unuseful.12- Did you have the TBT of the accident day ? - Yes , and the topics was to be More care while dismantling lash bar . No one work alone . Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future? - Take more care while I dismantle the lashing bar .Operations: Hatem Hosney Engineering: Amr Shorbagy HSE: Ramzy Maher + Ali Adel Possible 3 * Severity 3 = 91- Add the safe procedures of dismantling the lash bars to the lashing manual.-2 - Add this case to the TBT and highlight the importance of taking care while dismantling the lash bars.3 - Study changing the type of the lashers gloves to be impact resistant type4- Make lashers aware of thier surroundings , and take more care in the working area. Ops (Lash)

Ops

Ops + HSE08/09/2013

08/09/2013

Under studyNewMohamed Adel

10December 20, 201319:20Ops OrangeQCQC 10Injury case (LTI)6 MonthsKotbyOne of our Dowell men had injured while working onboard of M/V Antewarp, as he lifted up by the hatch cover for approx 2.5 meters.Immediate causes - The injured person fell down onboard of M/V ANTE WARP.

Underline causes - During discharging twin container, hatch cover was lifted with the twin container because there was twist lock not opened completely.- ASST D/W controller was under training and still not qualified to be responsible for vessel alone.- SCCT D/W controller took wrong decision when he decided to leave ASST deck controller alone on the vessel.

Root Cause People Cause:- Not following procedures:1- SCCT D/W controller left unqualified D/W controller to be responsible for the vessel alone.2- SCCT D/W controller didnt inform his SV before his leave.

Summary of statements Involved Person: Name: Amr Ahmed Shaaban ID: 8666 Department: OPS Position: ASST D/W controller (under training) Experience: 6 days

- I was on vessel with QC 10 & QC 11 and was working on bay 26 and 14.- When QC 10 hoisted up last twin container on bay 26, I noticed that hatch cover was lifted also because there were closed twist locks then QC 10 hoisted down the twin and hatch cover back to his position. The duel man made X signal with his hands for the operator to stop.- The Duel man went to the twin on the hatch cover to check and dismantle the twist locks then duel man made signal with his hands to the operator. The operator hoisted up again but the hatch cover is lifted again. In this time, I wanted to inform the QC operator to stop so I called on the radio QC10 QC10 but left sea side twist lock broken and hatch cover is hoisted down strongly and duel man fell down on the hatch cover because he was on the hatch cover in the same time.- I went to him to see what happened for him but he was shouting then the wharf came.

1. Did QC operator answer your call?- I didnt listen him.2. What was the distance when the operator hoisted up the twin with catch cover in the second time?- Approximately above 2 tiers.3- Where were your position and duel man?- In the first time, I was on left catwalk and duel man was on the other side (right catwalk).- In the second time, duel man was in the middle of hatch cover.4- Did you inform QC operator to hoist up?- No.5- What was the time between first hoist and second hoist?- Approximately 2 minutes.6- With who you was attach on the vessel?- With Tarek Mohamed (SCCT Deck controller).7- What happened when you received working on vessel with SCCT deck controller?- 1. we planned with foreman and dual man about working bays on this vessel. 2. we checked with foreman that bays are ready for work then he told me that everything is ok and he will go to pray for 5 minutes.8- Did he inform vessel SV?- I dont know.9- Did he inform you any instructions before leaving the vessel?- No, he didnt inform me anything.10- Can you deal with radio alone perfectly?- This was third time to deal with the radio but I cant deal with radio perfectly.11- Did you know the hazard of this situation, when hatch cover is lifted during discharging container?- No, I didnt know this hazard.12- Did you know all signals?- No.13- How many containers were handled before last twin?- Approximately three or four containers.Involved Person: Name: Tarek Mohamed El-Sehrawy ID: 621 Department: OPS Position: D/W controller Experience: 9 years

- When I received the vessel, QC11 was on bay 26 then QC 10 came to work on this bay and QC 11 went to bay 14.- I checked with foreman that the bay is ready for work.- I didnt pray so I informed my colleague who was under training with me that I will go to pray for 5 minutes then I went to pray.

1. Before your leave, did you give any instructions to ASST deck controller?- Dont leave the vessel until I will come.2. Did you check the hatch cover lock pins?- No, because we check hatch cover lock pins before discharging hatch cover only.- The normal that these pins must be closed by vessel duty.3- What did you have in the training about your job as deck controller?- First I plan with lash team for working bays.- I check with duel man and foreman that all twist locks are opened and bays ready for work.- Then be under call for any problem or changes. 4- If you noticed opened hatch cover lock pin on the deck, what you will do?- I will inform the vessel duty to close the hatch cover lock pin.5- Is this normal procedure that you can leave new trainee alone on vessel?- No.6- Did you take any instructions to leave the vessel in any time?- No.7- From your point of view, can ASST deck controller take decision alone in any case?- No, he cant.8- Did you inform your SV?- No.9- What would you do in this situation?- I would inform duel man and QC operator to stop until check and solve the situation.Involved Person: Name: Mohamed Elsayed Helmy ID: 911 Department: OPS Position: QC operator Experience: 2 years

- I was working with QC 10 on bay 26. SCCT deck controller told me that bay 26 ready for operation.- I handled 2 twin containers in 1st & 2nd tier.- When I hoisted up the 3rd twin, I noticed that middle twist locks quay side were closed so I hoisted down.- The duel man went to the middle to open the middle twist locks and he gave me signal to hoist up.- I hoisted up to distance less than 2 tier and waited until the duel man will leave the hatch cover.- When the duel man was directing to the left catwalk, I noticed that hatch cover is lifted because there was left twist lock sea side not opened completely so I wanted to hoist down but unfortunately the twist lock broken and hatch cover back to his position strongly.- The duel man fell down on the hatch cover.

1. Did you listen any call from deck controller?- I heard call in radio QC 10, please stop but I couldnt do thing because twist lock broken.2. Did you know deck controller who was with you?- No, I didnt know.10- Did you depend on signals in case of any problem?- If I understand the message from signals, I dont need help from deck controller .11- If there was experienced deck controller, what would happen?- This accident wouldnt happen.12- How can we avoid this situation repeated again?- The catch cover lock pin must be closed.Involved Person: Name: Mohamed Hamid Ibrahim ID: 816 Department: OPS Position: D/W controller Experience: 6 years

- I was working under QC 11 with ASST D/W controller trainee and QC 10 was near to us.- When I went to call TR driver to enter the lane, I saw lifted hatch cover then hoisted down strongly.- I went up the vessel immediately and saw duel man fell down on the hatch cover and shouted. ASST D/W controller trainee was with the duel man.

1. Did you listen any call on radio?- No, but I asked the deck about his action. He answered that he said QC 10 QC 10 on the radio to tell the operator to stop.2. Is this normal procedure that deck can leave new D/W trainee alone on the vessel?- No, this is not right.- We can do this action after we must ensure from his ability to take decision alone.3- Did you have any instructions to check hatch cover lock pins before discharging process?- No.4- How can we avoid this situation repeated again?- In case of feeder vessel, we must ensure that all hatch covers lock pins closed.Operations: Mohamed Adel + Ahmed Hegazy Engineering: Ahmed Salah Elden (Act ESM) HSE: Mohamed El-TabeeySeverity 3 * probability (1) = 31. Add new instruction to D/W controller SOP that deck controller must ensure that all hatch cover lock pins are closed before discharging process on the deck.2. Update the discharging procedure that nobody should be on the hatch cover when discharging boxes from the same hatch cover.3. Add potential falling hazard from hatch cover to the risk assessment of the discharging process. This hazard may result because of twist locks not opened and hatch cover lock pins opened in the same time during discharging container from vessel deck.4. Provide deck for each crane.5. Add this case to TBT and highlight the following: 1- D/W controller mustnt leave new trainee alone on vessel. 2- D/W controller must inform his SV, if he need to leave the vessel.6. Make awareness for all D/W controllers about new agreed instructionOPS25/12/2013OpenAhmed Hegazy111213141516171819202122

Issue #: 02 issue date: 01/07/2011 Revision: R001 Revision date: 22/06/2011Notes:

1-Date: will be in the form (January 1, 2009).2-Deadline: Must identify the exact day ex. (January 7, 2009).3-Time Of Incident: Must identify the exact time by code ex. (12:00 AM/PM)4-Equipment Type:to be according to the standard appreviation.Notes:

1-Date: will be in the form (January 1, 2009).2-Deadline: Must identify the exact day ex. (January 7, 2009).3-Time Of Incident: Must identify the exact time ex. (10:20) AM/PM.4-Nature of Damage: Must identify as follow (Damage,Near Miss, Injury).

F-03-02Last update to the sheet 05-01-2014 (please don't update any further data) QHSE (Wael. Haggag)For Any update - please contact QHSE section

Damages

Corrective/Preventive Action follow up (rolling document)

ItemCMO reference DateTime Of IncidentRelated toEquipment (if applicable)Contractor CO.Corrective ActionStatus (open/closed)New Penalty Code (if applicable)SYNERGY NOSupervisor responsibilityTypeNumberCase Explanation Root Cause (As per preliminary investigation findings)Employee statement summaryPreliminary Investigation ByRisk ValueActionOwner-shipDeadline1January 1, 201305:00:00 PMOPS OrangeRTG15please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient RTG 15 Lift Twing Container With Spreader On 40 Mode Which Lead To Spreader Chain Cut.( No Damage Happen On Containers ).People cause:1. Lack of attention (the QC operator wasnt attention that the twin mood not opened during handling twin container).Involved Person: Name: El-Sayed Mohamed El-Aboty ID: 1451 Department: OPS Position: QC Operator Experience: One year and 2 months

I was working in 05 B 06 and handled three twin containers and then my supervisor informed me to go to another bay to handle 40 feet containers and then I went to 05 B 06 again to complete twin containers.Before handling twin container, I opened the twin mood and I saw the twin mood lamp switched on and then I hoisted down and catch the container. When I started to hoist up the container, I noticed that container is free from middle and I called my supervisor immediately.

1- Did you sleep well?- Yes.2- Did you see the twin container when they down?- No, I didnt see and the vision wasnt clear because there is steel bar on the mirror in RTG 15 only but I saw twin lamb only.Operations: Mohamed Adel Engineering: Mahmoud Dorman HSE: Mohamed El-TabeeyRisk= Probability ( 3 ) * Severity ( 2) = 6Add this case to TBT and highlighted the following:1. RTG operators must be more attention during handling twin containers.2. RTG operators must ensure that the twin mood opened from twin lamp or visual check)OPSJanuary 8, 2013OpenSameh Haggag2January 2, 201302:15:00 AMOPS RedQC9please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient while operator QC09 loading in below deck he forget to command flipper upwhich caused damage to four flippers and one flipper motorLake of attention operator was not being attention to the spreader condition .While I was working in the cargo deck and in the second move I didnt check if the flippers were up or no and it was down and hit the deck walls.Operations: Hatem Hosny Engineering: Mahmoud Dorman HSE: Mohamed MashhourRisk= Probability ( 3 ) * Severity ( 2 ) = 6Add the case to TBT OPSJanuary 8, 2013Open3January 3, 20133:45:00AMOPS OrangeQC16please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient CQ 16 loading on bay26 hit 45ft CTR in bay 22 causing damage in flipper SQ211. People cause :- Lack of experience (the involved QC operator doesn't have enough experience and he made fast trolley).- Poor decision making (the involved QC operator took wrong decision when he made fast trolley)Involved Person: Name: Nader mossy Mohamed ID: 920 Department: Ops Position: QC operator Experience: 6 months

I charged 45 ft container on vessel in the third tier and then I started to charge 40 ft container in the beside bay.I must put the container from 45 ft container bottom and I put the container and then I made hoist up for short distance and made fast trolley, unfortunately right quay side flipper was stuck in 45 ft container corner and damage in flipper is happened and flipper fall down on deck.

1- Did you see the flipper stuck in container?- Yes.2- Why you made fast trolley?- I didn't think what happened.3- Did you expose to this situation before?- No but in this vessel, bays was very near because there is no walker.

How do you think this incident could be avoided in future? - In this kind of vessel in which bats are very near, 45 ft container must be charged in last Operations: Mohamed Adel Engineering: Mahmoud Dorman HSE: Mohamed El-TabeeyRisk= Probability ( 3 ) * Severity (1) = 31. Add this case to TBT and highlighted that QC operators must be more careful in this cases and take right decision and made slow movement to prevent any damage during spreader stuck.

2. 45 ft container must be charged in last on vessels which doesn't have walker between bays and bays are near.

OPS

OPS - OPS training

08/01/2013

03/01/2013

OpenSameh Haggag4January 3, 201320:00OPS OrangeQCCQ 08please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient Spreader stuck with the vessel, After releasing spreader from the vessel ,inspected hoist wire ropes and found both wires need to be replaced.Immediate causes Obstruction ( Many dents in the cell-guide ).

Underline causes Wrong handling. Root Cause Organization Root cause:1- Management & Supervision( Decision Process ) - Deck controllers numbers not adequate with the working loads. Involved Person: Name: Ahmed Mostafa ID: 1254 Department: Ops Position: Quay Crane Operator Experience: Two years.

Please advise how the incident happened ?

- I was working for loading containers in this bay, while I made a hoist down in this raw, I found the container stopped from the right side & still moving from the left side, stopped immediately to avoid any damage may occurred. How many containers you loaded in this raw?It was the 1st one. Did you noticed any damage in the cell-guide ?For this time no, but we know this vessel & we know its cell-guides are very bad. What was your speed in the hoist down move?Very low. Did you ask the deck for assistance?No. Why you didnt ask him for assistance as you have the knowledge about the bad cell-guides?Because we are working by only one deck for 2 QC, so we take to be careful then ask him if we need that, but if I ask him for this case as an assistance, it means that I have to ask him every move. Where was the deck ?When this case happened & the crane made the overload alarm. I saw him came from the other crane. Did you heard any stop word or any alert word from the deck controller ?No. Did you saw the damaged cell-guide before handling ?No. In your point of view, what was the reason of this incident ?Number of Deck controllers, we made extra efforts to avoid incidents & we are working in very narrow areas from long distance, so we need the deck controller to be with every QC operator to help him. If the deck was with you in this case, did you think that this case may be avoided?Yes. Why you didnt attend the TBT ?Because I came early.

Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future? - Deck controller with every QC operator.

Witness Person: Name: Mina Girgis ID: 1953 Department: Ops Position: D & W controller Experience: 4 Months Please advise how the incident happened ?I heard a voice of overload alarm from QC 08, directed to it & noticed that the spreader stuck from the right side & the left side still moving. Did you tried to alert the QC operator?Yes, but I think that he didnt hear me due to channel was busy. Could you advise the speed of the moving?Very low as normal. In the time of this case, where you was?With QC 07. How many hours did you spent on this vessel?1st hour. Did you check this bay before working ?No. Why you didnt check it?Because I received this bay working for loading. Did you received any hand-over from your previous colleague about this bay?I didnt receive any hand-over, because my colleague left the crane before my arrival, as he was from the previous shift. Did you worked on this vessel before?No, it was the 1st time that I came onboard this vessel. How do you think this incident could be avoided in future? Deck controller with every QC operatorOperations: Mohamed Adel Engineering: Mahmoud Dorman HSE: Mohamed AbbasProbability ( 5 ) * Severity moderate ( 3 ) = 15 1 To provide deck controller with every deck.2 To assign deck controller with every crane with the vessels which famous by the bad Cell-guide. ManagementShift Operations Superintended.Under processTo be implementedOpenManagement5January 4, 201311:15OPS WhiteRTG39please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient while RTG 39 was reversing back from 06 C to 06D and TR19 was waiting to pass to quay, the RTG hit the TR.Immediate causes

1. Wrong position of the TR.2. Engine Failure of the TR.

Underline causes

1. Failure to act from TR driver. (Stopping the TR behind the RTG & Using the TR hand brakes).

Root Cause

1. Not Following Procedures from TR Driver.

Involved Person: Name: Waleed Ahmed Aly ID: 3670 Department: OPS Position: TR Driver (Kotby) Experience: 6 Months

I was working with TR 19 at 07 E and when I was going out from the block toward the quay, I found RTG 39 going out from 07 C so I stopped at 07 D to wait for the RTG and see where it will go, suddenly I found him moving towards me then I tried to move the TR quickly but it did not move because the air was evacuated so I used the horn to draw the operators attention but the RTG hit the TR. Why you stopped behind the RTG?To wait and see where it will be directed. DO you know that the SOP is to change your direction not to wait the RTG direction?Yes I know. Did you use the hand brake ?Yes I did. Where was you stopping?I was stopping at the right to have a chance to escape.

Involved Person: Name: Mohamed Nasr Nasr ID: 1362 Department: OPS Position: RTG Operator Experience: 1 Year & 6 Months I had finished my work at 07 C and was going to 07 D, after making wheels turning on the plates, I moved with the RTG then I heard the sound of horns so I stopped and moved back. Did you turned the seat before moving?Yes I did but the TR was at right behind the RTG leg so I could not see it.Ehab ZahranAhmed SalahAhmed El-MarasyProbability 3 * Severity 1 = 31- Send the TR driver to the Training for a one day refreshment sessions about the instructions and procedures of traffic.2- The case to be published for all TR drivers at the daily safety talks. OPSJanuary 20, 2013OpenSalah Abd Elaziz6January 9, 20136:30OPS RedTRA53please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient while operator TT53 Entering 02G The truck slipped which lead to collides with TT90 caused damage to both TT&TRTR 53 Collide with TT 90

Underline causes

Driving in bad weather (very cold and rainy )

Root Cause 1- People causeFatigue(overwork/lack of rest/breaks) 2- Environment causeExposure to extreme/unexpected weatherMohamed Mohamed Elfeeky ID: 3415

Department: OPS out source(Kotby) Position: TR Driver Experience: 18 months I was in my way to 02 G in opposite direction in order to handle reefer unit ,after I enter the G block I adjust my TR exactly in TR lane under RTG then I feel doze till collide with front TT .-Does tour TR (53) have any abnormality in braking system or defected front glass?No .braking was in good condition but I didnt use it .-How many hours did you slept before coming night shift?7 hr-Did you take any drug makes you sleep while driving ?No-Did you face same situation before ?No-From your opinion what is the cause for this accident ?It was very cold night and last hour in the night shift which make me fatigue and sleptOperations: Nader Helmy Engineering: Wael Abd ELfatah HSE: Mustafa FathyProbability 5 * Severity 1 = 5Add to TBT to all TR driver to inform TR SV in case of feeling sleepy of fatigue .OPSJanuary 21, 2013New7January 12, 201311:00ops whiteTRA47please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient while TR47 attached with TT30 reversing back hit OPS-PU-40 which caused damage in the pick up.Immediate causes

Reversing back with the TR with a blind point.

Underline causes

The TR driver was harrying up.

Root Cause 1. People cause :- Lack of attention- Not following procedures.Involved Person: Name: Ahmed Mohamed Abd El Hameed El Zahar ID: 3671 Department: Ops (El Kotbey) Position: TR driver Experience: 7 months

I was going to my address at 03P inside the costumes area to get a container, I was driving between 3 K and 3 L and when I start to turn to right with the TR head between 3L higher and lower (the trailer was still in the way between 3K&3L), one of the x-stuffing labors stopped me to ask me about the container which I will charge, and ask me to get back and wait the RS in the way between 3 K and 3L because the RS wasnt reach 3P yet and the area was crowded with people, so I started to reverse back with my TR so the trailer center hit PU 40 right mirror .1- Did you notice that the Ops PU 40 was existing before you reversed back?- Yes, I saw it and passed beside it before turning right, but when I reversed back I forgot its existence because of my conversation with the x-stuffing labor.2- Did you look at the TR mirror while reversing back?- No, the area which Ops PU 40 was waiting as a blind point cant get by the lift mirror, because the heat and the trailer not in the same line (the head only turned right).3- Did you know that reversing back in the yard is forbidden ?- Yes, but I need to.4- When did you can reverse back in the yard if you need to do it?- There must be an observer to guide me to reverse back if I need in safe matter.

Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future? - Be more concentrate and call an observer to guide me reversing back if needed. Operations: Ehab Zahran Engineering: Mohamed Hadidi HSE: Ramzy Maherpossible 3* minimum 1 = 31-Add this case to TBT and highlighted the importance of following the procedures of never reversing back unless in the presence of an observer and with clear view.

2- Make reassessment to the driver and driving roles refreshment.1- ops2- ops + ops trainingJanuary 18, 2012newSameh Haggag8January 14, 20137:00Ops BlueQC10please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient While CQ 10 was discharging twin containers from under deck, the sea side right wire rope was damagedInvolved Person: Name: Mohamed Hassan Rizk ID: 0112 Department: OPS Position: CQ Operator Experience: 7 years

I was discharging twin containers from M/V XIN NAN SHA when the vessel supervisor asked me to discharge one twin from another bay, I moved by the crane to this bay and started to hoist down on the 8 tier under deck, the spreader landed on the twin but there was a problem on the locks of the spreader so, I called the deck controller to visually check the position. He arrived and told me that the position is clear and asked me to hoist up and try to hoist down again to solve this problem, I did so but the problem was still exist then he asked me to hoist up gain but while hoisting up the spreader left side raised but the right side did not. After that we stopped and called the ENG team. Was you hoisting down in full speed at the second time?Yes, I was inside the cell guide and this is a normal movement. Was the wires slacked?Yes it was. Did the crane movements stopped ?No, it was working normally. Was you able to see the position you was working in?No the vision was not clear because it was shaded and the time was early morning. Was there any deformation at the cell guide?No, the spreader moved smoothly inside it.Witness: Name: Mohamed Abd Elhamed ID: 1344 Department: OPS Position: D&W Controller

We was working on M/V XIN NAN SHA and I was with CQ 11 while I heard a call from CQ 10 operator to check the position of the spreader under the deck of central hatch, I directed there and checked the spreader and the position was clear but the spreader was not able to lock on the containers, I asked him to hoist up then down again on the containers to solve this problem then he hoist down in full speed and the wires slacked but the problem still exist. I asked him to hoist up again and try to close the spreader to 20 mood then open it 40 but when he started to hoist up the left side hoisted but the right didnt so I told him to stop and called the ENG team. Did the cranes movements stopped after the slack?No it did not stopped as he hoisted up again. Did you see any defects in the wire rope?Yes, after the left side raised and the right did not I saw a defect at the wire on the sea side right. Was there any defect at the cell guide?No, the cell guide was in good condition.Ahmed HegazyAhmed Salah Ahmed El-Marasy & Hesham IsmailProbability 5 * Severity 3 = 159January 15, 20132:30ops whiteQCQC 11please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient During QC 11 loading container No.MRKU6842313 On M/V CMA CGM MAUPASSANT Bay 17 the container hit the cell guide head which cause the container damage from the bottom Immediate causes QC operator failure to act with handling the twin containers roughly while the twin containers were vibrated. Underline causes Working in a blind point without observer (deck controller).Root Cause 1- People cause :- Poor decision making from the QC operator (working in a blind point without deck controller)2- Organization cause:- Lake of supervision due to lake of deck controller numbers.Corrective actions taken Live - Secured the spilt cargo area with cones. - Handled the damaged container and send it to the x-stuffing area to re-stuff it in a good condition one.- Clean the cargo spilt. Involved Person: Name: Ahmed Mustafa El Nahas ID: 117 Department: Ops Position: QC operator Experience: 8 Years

I was charging a twin containers and one of them (the damaged one) was heavy than the other and that made the spreader was trim itself due to the heavy weight of the container, and while I made trolley toward the vessel, I made trim position but in the opposite side to make it balanced this cause a vibration to the wires due to its elasticity (normal condition) , and when I reached to my addressed row (5th row sea side) I started to hoist down with the Two containers under deck, but it was a blind point to me because the previous row (6th row sea side) was 5 tiers height above the deck, then I found the containers stuck with the cell guide head.

1- Was it the first move in this bay (5th row sea side)?- Yes.2- What was supposed to do when you found that you will work in a blind point?- Work carefully and call a deck controller to be with me.3- Did you call the deck controller before working in that blind point?- No, I called him after I noticed that the twin containers were stuck.4- Why you didnt call him to guide you in this blind point?- I know he was busy with other QCs in the same vessel because I heard them, and if I call him he will come late and this will delay time.5- What was the circumstances that cause this damage?- First when I made a trim to make balance to the spreader, it vibrated due to the elasticity of the wires (normal condition) and while hoisting down with that vibrating motion made the spreader stuck with the cell guide.- Second the middle hatch cover in the previous row had a part was taking a space of my current charging row and I didnt know that because it was a blind point and I informed by this part when the deck controller was with me adjusting the position together when I charging the 2nd twin containers after the incident.

Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future? - A dick controller must be with me to supervise such situationsOperations: Ehab Zahran Engineering: Mahmoud Dorman HSE: Ramzy MaherPossible3* Minor 2 = 61- Add this case to TBT and highlighted the importance of calling and providing every QC is dealing with the blind points on vessels with deck controller.

2- To provide deck controller with every QC.1- Ops2- Management1- 21/1/2013

2- under processnewJosh10January 19, 201322:00OPS OrangeRTGCR 36please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient HIPO While RTG 36 loading from Bay 33 Row F ,It Hit another container from Bay 35 Row B.Immediate causes Container hit by another one.

Underline causes Wrong handling. Root Cause Environment & Effects:5- HousekeepingStaking / Storing. ( Bad stacking ).Name: Medhat Samir ID: 1043 Department: Ops Position: RTG Operator Experience: 3 years.

Please advise how the incident happened ?

- I was working for loading containers in bay 25, finished my working in this bay, then directed to bay 33, Start my moving in this bay for single container, suddenly I surprised by the containers fall. How many containers you loaded in this bay?It was the 1st one. Could you advise the procedures that you trained on while handling 1st container in yard ?To adjust the RTG on the bay, then address to the required container for loading, then some adjustments by the spreader to move it. While your adjustment the spreader to take the container, did you take it from the 1st time?No, made some adjustments. Did you make a gantry move?Yes, but slight moving. Gantry move for right or left direction?I cant remember. What are the surroundings required to be checked during handling?The height of the containers in the bay.

Did you felt anything wrong or something stuck during your back trolley movement?No, I surprised by the incident. Did you try to avoid this damage?After I saw the containers fall, I stopped trolley movement. Whats your trolley movement speed?The normal. It was full speed?Yes. Why you moved in full speed, as you are in 1st container in this bay?Because I checked the height of the rows from A to F & found that all are in the same which I handle from row F, then the speed of the trolley will be limited when it will reach row A. Did you check the distance between the containers in your bay & other bays ( 31 & 35 ) ?No. Why you didnt check this distance?Because I put all my concentration in the height of the rows in the same bay of my working operation. When you make trolley forward to take this container, did the spreader hit or touch any containers from bay 35 ?No, because I entered from bay to bay & the spreader was higher than the containers. Did you faced any technical faults in the RTG which may lead to this incident?No. Are you slept well?Yes, approx 7 hours. Did you suffer from any home conditions which may affect on your concentration ?No. During the incident, you was calling in phone / Speaking with anyone in the SG phone?Before the incident & before handling the container, I was talking with tower controller in some issues regarding to the operations, but while I was trolley back; I didnt use anything except the stick. In your point of view, what is the reason of this incident?Bad stacking. Why this behave repeated this days in your opinion?- I dont know, but from long time, yard supervisors give a negative comments to the operator who made the wrong stacking & I think the training in the last period not covered all activities.

Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future? 1- To check the bad stacking bays .2- Operators must be careful during handling.RTG Trainer: Name: Kamel Kamel ID: 0346 Department: Ops Position: RTG Operator (Trainer) Experience: Well experienced, as he RTG trainer.

Could you advise the procedures must followed while handling 1st container in yard ?To adjust the RTG on the bay, then address to the required container for loading, then some adjustments by the spreader to move it, need some check for the row heights & surrounding factors which may affect on handling. The surrounding factors means what ?Everything may affect on the safe handling. Should the operator check the distance between the bays ?Yes. Sameh Haggag / Adel Khedr Ahmed Salah Mohamed Abbas / Mohamed Eltabeey.Probability ( 5 ) X severity (3) = 151 To make a daily random check for the wrong staking in the yard, then re-stack in the proper way & to be reported as observation .2 To add every observation of bad stacking in the log file by the name & ID of the involved operator then to collect the repeated names to be sent to Ops training for re-assessing this operator.3 To add this incident to the TBT & highlight the importance of stacking in the proper way & to check the distance between the bays before handling any container.Ops Yard SupervisorOps OpsDaily ( Starting from 20/01/2013 )To be implemented28/01/2013NewSameh Haggag11January 21, 201317:30WhiteTRATR 93please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient While TR 93 moving on one of new unfixed gutter covers it hit the truck stairwayImmediate causes TR moving on unfixed heavy gutter cover, which moved and it the TR stairway. Underline causes The gutter was un fixed with its bolts.Root Cause - Inadequate construction fixation. Involved Person: Name: Mohamed Mohamed Abd El Maksood ID: 3219 Department: Ops (Trademare subcontractor) Position: TR driver Experience: 2 Years

I was charging a container under QC 11 and this was the first containers charged on the vessel and the wharf told me to move and wait behind the QC until finishing the movement confirmation then I drove my TR from under QC 11 through QC 12 and take a maneuvering and to enter the waiting area behind QC 11 and while I drove in the waiting area behind QC 11, I heard something wrong happened, I stopped to see what happened, then I found one of the gutter covers hit and stuck with the TR stairway.

1- After inspecting the incident site we found one yellow barrier beside the rain gutter, did it barricaded this area as a working area?- No, the barrier was as you see it when safety and engineering came, it was away from the rain gutter.2- Did you hit the barrier and remove it from the gutter cover when you entered the waiting area behind QC 11?- No, I didnt even touch it. Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future? Mohamed HegazyAmr El ShorbagyRamzy MaherUnlikely 2 * Minor 2 = 4Make a survey for all the new gutter covers for standing on its fixation status on the ground and to start fixation process. projectwaiting project respondnewJosh12January 24, 201316:30OrangeTRA111please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient During operation, Truck 111 hit container TRLU7510791 when the driver made maneuvering under the RTG which was in 03 A 02 (First bay) cause dent in the right side corner pustPeople cause:1. Lack of attention (the involved TR driver wasn't being attention to his left side and concentrated on RTG side only).Involved Person: Name: Mohamed Mohamed Abdel Aziz ID: 3587 Department: OPS Position: TR driver (Trade mar) Experience: One year and 4 months

I was in my way to 03 A 10 and there was RTG stopped in 03 A 02 (first of bay). When I made maneuvering under the RTG, the RTG made gantry alarm and I confused and I was be attention to the RTG side only and my TR 111 hit the container.

1- What are the safety traffic procedures during maneuvering under RTG?- I must be more attention to RTG and container and use mirrors and take safe distance.2- There are any problems in your mirrors?- No, mirrors are good.3- Why you didnt use the left mirror?- Because when the RTG made gantry alarm, I confused and concentrated only on RTG side because I was afraid that RTG will hit my TT.4- Did you sleep well?- Yes, I slept very well.5- Did you have any family problems or in work?- No.6- There was any spillage surface during maneuvering?- No.Operations: Adel Khedr Engineering: Said Abo El-Enen HSE: Mohamed El-TabeeyRisk= Probability ( 3 ) * Severity ( 2) = 61. Add this case to TBT and highlighted the following:1. TR driver must be more attention and concentrated to both sides of TR during maneuvering under RTG in first of the bay.2. TR drivers must use left and right mirrors.

2. Send the involved TR driver to training for re-assessmentOPS

OPS training31/01/2013

25/01/2013OpenJosh13January 26, 201317:10Ops BlueRTG47please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient RTG 47 HANDLED GESU9457559 from 02H 14 G4 without previous confirmation from reefer People cause:1-1-lack of attention. (using new reefer unplugging system)2-poor decision making. (checking with reefer technician after loading the container)Ops: Ahmed HegazyEng: Ahmed ShawkyHSE: Hisham IsmailRisk= severity(1)*likelihood(5) = 51-To be discussed during TBT about the importance of pre-checking of plug/unplugging reefer sockets.

2-Refreshment for RTG operators about new reefer socket system.OpsOps 14-02-201314-02-201314January 31, 20136:30whiteRTG20please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient RTG 20 lifting the twin as 40 without calling twin bottomImmediate causes RTG operator handled a twin containers as 40 ft. container.Underline causes 1- RTG operator didnt check the location shown in the system.2- Bad visibility due to bad weather (heavy rains).Root Cause - Lack of attention. Involved Person: Name: Abd Allah Ali Mosa ID: 1446 Department: Ops Position: RTG operator Experience: 18 monthsIt was rainy and I was in 8 B lower then I checked my screen and I found that I have to discharge container in 08 B 54 and the others in 08 B 63 so I decided to begin with bay 54 container, when I reached I found a truck was waiting in the location 08 B 54 with a single container (20 ft. container) but it wasnt its location so I called its driver to move from down there to allow the right address TR to enter down me, then the incident involved TR came under my RTG and I started to handle the container from it as 40 ft. container not as a twin container so one of them fall down on the trailer and the other was stuck.

1- Could you know the type of containers ( 40 ft, 20 ft or twin containers) that you will discharge from the system on RTG screen?- Yes, it is shown in the screen.2- So what happened to make you took the twin containers as 40 ft. container if it shown in your screen?- It was rainy hard and the visibility was not good and the two containers had the same color so I thought it was 40 ft. container.3- Did you check the no. of the container with the number of the container you should discharge in the system in RTG screen?- Yes, I checked the TR number on the system and it show the same number of one container of the twin containers but I didnt check the location of this container, the location of this container was in 08 B 63 but I was discharge it in 08 B 54.4- When you checked the container no., did you check its location?- No, I didnt check it, I only compared the numbers of the container with number in the system. 5- Was there any TRs waiting in front of the involved TR when you reached to bay 54?- Yes there was two other TRs in front of it, one of them was waiting at bay 54 which I called it to move to allow the right address TR to enter down me

Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future?1- When the visibility is not good, I must call the yard supervisor to help me.2- Make a sensor to the RTG spreader to recognize the twin containers from 40 ft. container like the sensors exist in the QCs spreaders. (refused from Engineering dep.)Operations: Mohamed Seif Engineering: Wael Abd El Fattah HSE: Ramzy MaherProbability 3* severity 1 = 3Add this case to the TBT showing the importance of 1- RTG operator must assure that the number and the location of the container in the yard is identical to the number and location of the container in the system.2- If the RTG operator visibility is not good, he must call the yard supervisor to help him opsFebruary 5, 2013newAmr Rashwan

15February 1, 20132:00OPS RedTerminal BusOPS BS 08please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient While bus 08 was moving from the Qsideto muster room parking he colllides withTT 16 attached to TR05Immediate causes

BS 08 collide with TR 05

Underline causes

N/A

Root Cause

1-Lack of attention/due care2- Not following/incorrect following of standards/proceduresAmr Mahmoud Hamed ID: 1527

Department: OPS Position: Bus Driver Experience: 5 years.

I was coming from Q side to muster room between 02 H &L when I reach main drive rood after J I check my right direction only ,I decide to continue moving but unfortunately when I look to my left side I surprised by TR 05 coming so I stopped but the TR hit BS 08 front.

-How much your BS speed ? About 25 km /hr-Did you stop at stop sign before main road ?No ,I didnt-Did you stopped by using brake or by collision effect ?I used my brake when I see the TR coming from my left .-how many hour did you slept before coming night shift ?5 to 6 hrs and this my normal .-Do you have any problems affect your attention while driving ?No all things is OK internally & outside CO.-How do you think we can avoid this Accident ?I dont know.Nader Helmy Engineering: Ahmed Shawky HSE: Mustafa Fathy likely* min = 41-ENG TS to paint new stop sign at the end of J block same like phase II 2-Involved Driver get out of OPS Rooster till re-assessment 3-TR Supervisor to highlight our traffic rules & traffic priority during daily TBT ENG TSOPS -TrainingOPS - Execution1-Waiting TS advice2-Already done 07/02/20133-15/02/2013NewAmr Rashwan16February 4, 201323:50OPS OrangeRTGCR 40please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient RTG lifted up connected reefer without any notice from reefer technician.Immediate causes

( Lack of communication Miss understanding the message )

Underline causes Wrong handling.

Root Cause People cause:1- Activities & tasks. ( Operator not following the procedures ).Name: Mohamed Mohsen ID: 0631

Department: Ops Position: RTG Operator Experience: 4 years.

I was working at RTG 40 by the mobile, because the Mic, tower telephone & RTG telephone were not working, so tower controller called me on my mobile & the supervisor give me the instructions also by mobile, while I was working; my direct supervisor inform me to start loading row F, while I loading the container in F 1, suddenly the RTG stopped due to the emergency button released & informed by YSV that this container wasnt unplugged & asked me to continue handling, after this case, he informed me that he didnt inform me to load this container & he just inform me to load in F 2 & 3 only, but I think that he informed me about all containers in this raw. How many hours you are worked on this RTG?Approx 1 hours. Did you informed your direct supervisor about the defects in the RTG?No. Did you checked this defected devices before working?Yes. Why you didnt report to your direct supervisor?Because my colleague who I received from is the responsible to report. Did he inform you about reporting by the defected devices?No. Are you asked him about that?No. Are you aware about the system of reefer handling?Yes. Did you followed this system during your working hours?No, because it wasnt working & but after you left the RTG, someone from IT accessed to the monitor & activated the system. Are reported to your supervisor about the breakdown of the system?No. Why?I preferred to work manually When I was in your cabin, I ask you to show me how this system working, but you cant reach this system; as you tried to open it but you didnt find it, my question is : Are you used to work without this system or working by it?Without it. This system installed from approx 6 months, during this period you used this system?No. Why you didnt use it?Because sometimes containers appeared clear & ready for loading , but when we check it before we found the cables is unplugged. Are you trained about how to use it?Yes. Are you slept well before working ?Yes. Did you have any home circumstances which may affect on your concentration?No.

Did you receive a pre-shift safety talk: YES NO

Did you receive training in how to do the task involved: YES NO

Are you aware of the rules / procedures related to this work: YES NO

If required, were you wearing the correct PPE: YES NO

Did you receive supervision in the last 1hr of your work: YES NO How do you think this incident could be avoided in future? 1- To check the communications devices & to report any defect.2- To follow the safe working procedures & the system.

Direct Supervisor: Name: Mohamed Elkammash ID: 0815

Department: Ops Position: Yard Supervisor

Did he/she give a pre-shift safety talk: YES NO

When was the last time you spoke to or witnessed the involved persons work During his working hours on this RTG.

Did you inform the operator about loading all F row?No, jut F 2 & 3. Are you aware about the defected communications devices?Yes & we reported all defected devices to Eng Dept. Did the operator reported to you the defected devices before starting his work?No.Walid Elkoraey Mohamed Hassan Mohamed AbbasProbability 4 ( Likely ) X Severity 1=41 Add this incident to the daily TBT & highlight the importance of following the safe handling procedures & the importance of reporting any defects.2 To assign the RTGs which working with reefer to be fully equipped by the communications devices.Ops

Ops15/02/2013

07/02/2013OpenedMohamed Elaraby175-Feb-1317:10OPS whiteTRATR71/ TR14please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient During the operation between QC 11 QC 12 when TR 14 comeback hit TR 71 make damage in the front of the truck and the glass broken . 1-Poor decision making. 2-lack of attention. ( only checking the mirrors one time not frequent checking).Involved Person: Name: Ahmed Mohamed Saad ID: 3662

Department: OPS Position: TR Driver Experience: 10 months While I was under QC 12 on lane 04 I decided to change to lane 06 I asked the wharf to move reverse he said its clear then I checked the mirror and while reversing I hit TR71.Q:Do you know about traffic SOPs in our terminal ?A:yes,Q:Does it mention that its possible to move reverse at any place in out terminal ?A:No. it doesnt.Q:So, why you moved reverse? A:Normally we do so if a Wharf is guiding me.A: Why you Hit however you have a guide?Q:because I start moving while he was not in back side of my track.Q:where he been ?A:he was next to my window he told me it was clear back and ask me to go on and I checked the mirror then I moved.Q:did you check the mirror carefully ?A: I checked the mirror once before start moving only.(Truck Supervisor asked)Q: did you left a safe distance between you and the front track ? A: yes I did.Q: are there any Trucks are next to you in lane 05 &06 ?A:No.Q:So, why dont you turn the wheels directly to the next lane as long its clear from tracks?A: I decided to do reverse as it was clear.Also Truck Supervisor added if you turned lift to lane 5 and 6 it would be more easier and safer than reversing your Truck.Operations: Ehab Zahran Engineering: Mohamed Ali HSE: Hisham IsmailSeverity (1) * Probability (4) = 4To add/highlight on TBT the case and inform all drivers about the importance of following the correct SOP.OPSFebruary 14, 2013Opened18February 3, 201313:35OPS BlueFL55please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient While TR 18 was moving from yard to the quay side, it collides with FL 55 and caused damage for FLPeople cause :1. Not following safe procedures (the involved FL operator didnt follow the safe procedures when he use wrong way).Involved Person: Name: Sami Attalla Elsaqa ID: 6019 Department: OPS Position: FL operator (Trade mar) Experience: two months

I was handling gearboxes for vessel in berth 4 and after I put the last gearbox in 04 M, I directed to QC 18 in berth 08 so I took my way from 04 M.When I was passing from berth 04 M to berth 05 M, TR 18 hit my FL at stop sign at quay side.

1- Did you have any instructions that you didnt use M area during passing from berth to berth?- yes2- Why you use your way through M area when you directed to berth 08?- Because there was TR crowded in the main road.3- What is your speed?- Normal speed.4- Why you didnt stop to check the road before passing?- Because I thought that I was far from stop sign and far from the TR and also there is no stop sign.5- Did slept well?- Yes, I slept very well.6- Were you occupied with anything during driving?- No.How do you think this incident could be avoided in future? - Must use the main road during passing from berth to berth.Direct Supervisor: Name: Salah Badawy ID: Department: ops Position: Lash supervisor1. Were there instructions for Fl operators that they mustnt use M area during passing from berth to berth?- Yes.Involved Person: Name: Mohamed Adel Taha ID: 3293 Department: OPS Position: TR driver (Trade mar) Experience: one year and 10 months

I was in my way between berth 04 and 05 (yard) to quay side and I started to slow my speed at 04 M.When I was near to stop sign, I noticed FL which came from 04 M L and used the brakes to stop the TR but unfortunately I hit the FL.

2. What is the safety traffic procedures during passing from yard to quay side?- I start to slow my speed at M to stop at stop sign.3. Were you occupied with anything during driving?- No, I was concentrated with my way.4. Did you notice the FL?- Because he was very near to OOG container and there was blind point.

Ahmed HegazyMohamed EltabeeyMohamed AofProbability ( 3 ) * Severity ( 1 ) = 3 1. Add this case to TBT and highlighted the following:FL operators must use the main way during traffic from berth to berth.

2. Add the following point in safety traffic SOP:Prevent any equipment or vehicle in M range.

OPS

OPS training

08/02/2013

03/02/2013

ClosedSalah Abd Elaziz19February 8, 201313:30OPS RedTRA125please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient the TR driver reverse to adjust the truck under the container with careless way leading to move the truck to the containerImmediate causes

TR 125 cabin collide with container

Underline causes

Tacking shortcut and breach SOP

Root Cause

1- TR Driver Careless 2- Not following/incorrect following of standards/proceduresIbrahim Mahmoud Ahmed ID: 3482

Department: OPS Out Source(Kotby) Position: TR driver Experience: 2 Years After discharging with QC 07 ,QC 08 Wharf show to me & ask to take container from QC 08 which was standby so I stopped in my Lane ,when the QC hoist down the container it was 45 so wharf ask me to move backward ,I set down and start reverse move then I use TR hand brake to stop the TR but the TR didnt stop and collide with the container .-when the Wharf controller ask you to reverse back , What was the position of the container ?Above the Trailer by approximately 1 meter .-Did the Wharf controller ask you to reverse quickly ?No.-Tell us what the sequence of your actions when Wharf controller ask you to reverse 1- I set down partially (shoulders towards right direction TERBREG Cabin door )2-relase Hand brake (it was applied when I stopped first time)3-change the Gear from N to R 4-start moving backward .5-apply hand brake again but this time the gear still on R mode .-During your Training or instructed by your TR supervisors ,is it possible to stop the TERBERG TR using Hand brake while gear on D or R mode ?No.Acc to your statement ,you didnt set down completely and move the TR ,Do you think you can control 100 % the TR in this position ?No.-Why didnt you set down in the normal position and move the TR safely and stand up again ?I was afraid from QC operator rough handling on my TT which will cause me low back pain .-Do you have any history of rough handling with 45 unit ?No. when we inspect the TR cabin we found that you use the hand brake arm as a holder for a plastic bag full of rubbish ,and one kiwi Fruit on the ground .-Do you know its not allowed to eat or drink inside any equipment ,and improper use of hand brake arm may cause any defect to its performance ?Yes I know ,I didnt eat inside TR but I eat before start work and I collect my rubbish to put in nearest scrap box .Nader Helmy Engineering: Ahmed Shawky HSE: Mustafa Fathy unlikely (1)* min (2) = 21-Involved driver out of OPS rotation till reassessment 2-Add this case to TR driver TBT and highlight the hazard &consequence of breaching SOP. 1-OPS Training2-OPS 10/02/201316/02/2013New20February 7, 201314:30OPS RedTRA97please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient During TR 97 make maneuvering in 07 G, it hit reefer stand and make damage in TT 141 and stand reeferPeople cause:1. Lack of attention (The involved TR driver wasn't be attention to his way during maneuvering).Involved Person: Name: Nagy Sami Fahem ID: 3316 Department: OPS Position: TR driver (Trade mar) Experience: one year and six months

I was in my way to 07 G (new reefer stands) and when I made maneuvering to enter the bay in north direction, I found External TR stopped under RTG in bay 46 so I stopped and waited the Ex. TR.After the Ex. TR left, I started to enter the bay but unfortunately my TT 141 hit the stand reefer.

1- What are the safety traffic procedures during maneuvering under RTG in the beginning of the bay?- I must take safe distance and use both mirrors and be more attention and slow my speed.2- Did you use mirrors?- No, I didnt.3- Why you didnt use the mirrors?- Because I thought that my TT was straight.4- Did slept well?- Yes, I slept very well.5- Were you occupied with anything during driving?- No.How do you think this incident could be avoided in future? - Must be more attention and must use mirrors during maneuvering under RTG.Operations: Nader Helmy Engineering: Ahmed Shawky HSE: Mohamed El-TabeeyProbability (3) * Severity (1) = 31. Add this case to TBT and highlighted the following:All TR drivers must be more attention during maneuvering under RTG.

2. Send the involved TR driver to training department for re-assessment.OPS

OPS training

11/02/2013

08/02/2013

NewAmr Rashwan21February 10, 201321:05OPS RedRTGCR20please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient RTG20 Handled connected reefer which caused damage to the socket @02G 46F2 with no previous notification to reefer Tech.Immediate causes RTG 20 Lift connected reefer unitUnderline causes Reefer LOG system cover OPS Vessels units only &didnt cover gate unitsRoot Cause Not following/incorrect following of standards/proceduresAs the operator hoist the connected unit before confirmation from reefer tech.Ramy Elsaid Shehata ID: 184

Department: OPS Position: RTG operator Experience: 7 yearsI have been informed from my yard SV to go to 02 G 46 for handling OPS vessels/OPS gate reefers, when I arrive I start 2 rehandle move 02 G 46 F4&F3 safely but when I handle F2 I found it was connected .

-Does your Yard SV confirm with you about F2 ready for handling?NO, but its logically if I have to handle F2 and found F3 & F4 unplugged F2 should be unplugged

-Did you check LOG system screen ?NO. I get confused when Yard SV was under RTG arranging Ext TR &Terminal TRs form loading and told me I will arrange the TRs acc to loading sequence so I understood that the units clear and ready for loading.

-Do you know that Gate reefers didnt connect or appear on LOG system ?NO.

-Did you take confirmation from reefer Tec. Related to this bay before handling ?why?NO. because there was a lot of EXT.TR & Terminal TR waiting in my range for long time and I thought all the bay ready for loading Nader Helmy Mohamed elhenawy Mustafa Fathymin 1*likely 4 = 41-Reefer to include Gate loading in LOG system ASAP2-Add to RTG operator TBT to wait confirmation from reefer before handling Gate units till LOG modification done ReeferOPSFebruary 20, 2013NewSameh Hagag222/9/1313:00OPS BlueRTGCR32please specify the contractor Co. name; if the involved person is the responsible (his mistake) for the incient While RTG 32 loading from 01H bay 10 hit container which located in row C3 which lead to damage in 2 Containers.

human error.over confidencewas Re-handling a container from G 3rd tier to A 1st tier then I landed the container and to free the container i give unlock command and it shows unlock to me and start handling for the next container, while hoisting up and trolley as I check there was only 1st tier in A and 1st tier in B and 3rd tier in C so I moved according to the view I reach to the top and found the hanging container hit the containers made them fall in bad D&E bays.

Q: do the vision clear in your cabin and the window is clean ?Yes,Q: How many hours did you slept before coming to the work ?I slept around 6 hours.Q: what do you think lead to accident ?A: It was my fault because I didnt check whether the spreader is empty or not.Also he added:The joystick in the cabin for lock and unlock command on spring means if you push forward it may return to the opposite direction and gives the opposite command. After checking the above mentioned from the operator on RTG 32 we found that: (after applying lock and unlock commands several times its working properly).He also mention the indication light inside the cabin for lock and unlock having the same color showing.( lock(Red) and unlock(red)).photo attachedAfter checking the cabin the light indication lamps for lock and unlock are red.Q:But in both cases it shows you not to raise the container because its locked ?A:yes I was just mentioning that, but I know the fault from my side.

Operations : Ehab Zahran Engineering: Sayed Abo-Elenieen HSE: Hisham A.Ismailseverity (