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DESCRIPTION OF THE ACT OR CONSEQUENCE LATENT FAILURE

SITUATION CATEGORY
1)Poor ergonomic design by the Allowed pump controlled to Design
console manufacturer be moved unintentionally

2) the Chief Officer left his VHF The ship did not receive the Communication
radio in the CCR warning from the terminal

3) The ship manager hiring too Defeated a system designed Defenses


few crew to monitor manifold to control, contain or mitigate
pressure gauges and rig portable the consequences of errors
pump and failures
4) Lack of practical understanding Allowed a warning sign to be Organization
in the ships managers office overlooked