MARITIME

Issue 66 February 2022

An independent and confidential reporting system for the maritime industry

SUBMIT A REPORT ONLINE BY EMAIL CHIRP always protects the identity of our Reports can be submitted easily through our You can send us a report by emailing CHIRP reporters. All personal details are deleted encrypted online form direct, we will always protect your identity – from our system once a report is completed. www.chirpmaritime.org/submit-a-report/ reports@chirp.co.uk

The CHIRP editorial

Falls, Fires and Floating Armouries Adam Parnell Director (Maritime)

Readers will once again notice the very high standard of the reports we are receiving, which is most encouraging. Our reporters seem to be able to overcome the present difficulties of life at sea to produce reports which are full of valuable safety lessons, and we are extremely grateful. Without them, our work would be impossible. There are a number of themes running through this edition. Working at heights is pertinent to reports about the maintenance of supervision is a matter of We hope you will be study. We repeatedly ask you accommodation ladders, a concern in reports about the to consider whether there are fall from a vertical ladder, use of inappropriate knots, inspired to suggest procedures in place on your and unsafe lifting points on a vertical ladders, the work boat, improvements if you own vessel to prevent the type work boat. Meanwhile, design and a tragic case of a fatality notice anything which of incidents described by our issues also feature in reports when working with a tug’s reporters, and we hope you about accommodation ladders, messenger line. poses a hazard to you will be inspired to suggest the deck layout on a log Navigation and ship or your colleagues improvements if you notice carrier, and poor construction handling also feature, in anything which poses a hazard standards which dissuaded a reports about a berthing to you or your colleagues. crew from doing maintenance. operation which went We are publishing this Poor maintenance is also badly wrong, and about edition during Lunar New an issue in reports about converging vessels in the Year, so we wish you all good accommodation ladders, a approaches to a port. fortune in the Year of the floating armoury vessel, a gas All the reports in this edition Tiger and, until next time, may tanker fire and the log carrier. can teach us valuable safety all your voyages bring you At the same time, proper lessons and will reward careful safely home.

Please note all reports received by CHIRP are accepted in good faith. Whilst every effort is made to ensure the accuracy of any editorials, analyses and comments that are published in FEEDBACK, please remember that CHIRP does not possess any executive authority.

MARITIME

Are you interested in becoming a CHIRP Maritime Ambassador? CHIRP and the Nautical Institute have an Together we can promote the development of a established ambassador scheme to raise ‘just’ reporting culture across the maritime sector to awareness of our incident reporting schemes and improve safety outcomes. The key attributes of a encourage the submission of incident, accident successful ambassador is a passion for safety and and near-miss reports. a willingness to speak up for CHIRP among your colleagues and contacts. We seek additional volunteer ambassadors around the world, especially in China, Cyprus, Indonesia, If this sounds like you, please contact us to discuss the Philippines, Spain and the USA. this opportunity at mail@chirp.co.uk

As an ambassador you will join an international network of seafarers who also share your passion for safety, and you will quickly gain a broad knowledge of current safety issues. These are great additions to your CV and increase your employability.

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M1852 SOLAS regulation II-1/3-9 states that all wires used to

support the means of embarkation and disembarkation shall Accommodation ladder fails be maintained as specified in SOLAS regulation III/20.4 which states that falls should be ‘renewed when necessary after pilot embarkation due to the deterioration of the falls or at intervals of not more than 5 years, whichever is the earlier’. Initial report Reducing the periodicity for changing the falls A pilot boarded a ship using a combination rig. After to between 18 and 30 months for vessels that have their embarkation, and while the accommodation ladder accommodation ladders in these exposed areas should be was being recovered, the wire falls parted, and the considered, as should changes to the design for securing accommodation ladder dropped to the sea and trailed in the the falls. However, thorough maintenance must always be water as the vessel was underway to the port. The Master provided to the wires, sheaves and fixtures no matter how alerted the pilot to what had happened when the pilot difficult the access to the wires may be. reached the bridge. A subsequent inspection revealed that the bolts securing the wire had failed. A full port state control inspection took place the next day following a report on the incident. The accommodation ladder had been inspected by a classification society 18 months earlier. The Master undertook remedial action with respect to the accommodation ladder and the fall securing.

The International Chamber of Shipping’s (ICS) publication “Shipping Industry Guidance on Pilot Transfer Arrangements, Ensuring Compliance with SOLAS” very clearly describes the safe rigging requirements for pilots, including outlining the responsibilities for shore and on board management plus details for rigging of trapdoor arrangements for combination ladders which is described in IMO resolution A.1045(27). Some shipping companies employ a permit to work (PtW) system for pilot boarding operations and CHIRP strongly CHIRP Comment urges all companies to consider adopting this idea as best Pilot boarding arrangements are regularly featured in practice: it is not onerous and can easily be added to the our Maritime FEEDBACK newsletters. However, the SMS. It would provide assurance to pilots that the vessel accommodation ladder is often perceived by ships’ crews takes their safety seriously. to be less of a risk because it is a robust structure and viewed as a part of the hull’s structure. Because of these factors, accommodation ladders can be overlooked when Pilots have the right to decline to board undertaking ladder maintenance, especially items such vessels offering defective boarding as the hull fixtures to which the wires are affixed. Like the pilot ladder, it is often difficult for a pilot to fully appraise arrangements, which can result in serious the safety standards of the accommodation ladder’s fittings delay [and] report … which could lead to a prior to boarding. This incident shows it is also an area of full port state control inspection with the risk vulnerability and CHIRP wants to highlight this. Many vessels, especially bulk carriers and tankers, of delay and financial penalties have accommodation ladders that are positioned on exposed areas of the main deck where heavy seas and The ICS publication makes a very important point with spray, combined with cargo residue and dust, can affect respect to human behaviour: “a pilot who has climbed a the fixtures and fittings and bring about accelerated correctly rigged ladder, and attended by an officer and a corrosion. Access is often difficult, hampering inspections deck party, will be in the right frame of mind to give their and maintenance. Design is a significant latent factor in best attention to the safety of the vessel.” In effect, the this incident, which could have had extremely severe pilot’s integration into the bridge team starts at embarkation, consequences for the pilot. and not when they arrive on the bridge. The photographs shown below highlight another failure of a gangway that has just occurred at the time of writing Human Factors relating to this report this report where the gangway wire had parted just after the Capability – Is your team capable of recognising a worn or pilot boarded the vessel. corroded securing fitting?

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Is your management team receptive to suggestions wanted to improve conditions on board. However, no for change for poorly designed equipment? Does your significant changes occurred so CHIRP passed the report company operate a Request for Change system? to the vessel’s registered flag state and its classification society, both of whom withdrew registration. This means that Culture – Is there a culture of checking items of equipment the vessel can no longer legally operate at sea until these to see if they are fit for purpose before use? issues are resolved. Does your company have a culture which does not A report issued by the United Nations Office for Drugs operate at the minimum standards and instead sets higher and Crime (UNDOC) in 2020 highlighted that there are no standards? Do you feel that your gangway wires could generally accepted international standards that directly be changed more frequently given that a person’s life is apply to floating armouries, nor is there an overarching dependent on their condition and strength? industry organisation that can set expected minimum What procedures does your company employ to confirm standards to which the companies providing armed guards that the pilot boarding equipment is safe to use? Does your can adhere. Furthermore, because floating armouries company have a permit to work system for pilot operations? operate in international waters for lengthy periods it is difficult to enforce compliance to national or international Local practices – Is the rigging of pilot ladders part of your regulations because such inspections almost always take vessel’s Permit to Work system? place only when the vessel is alongside in port. Unlike the crews of the floating armoury vessels, the armed guards are not recognised as seafarers under the current IMO definitions, but rather viewed either as M1787 “passengers” or “industrial personnel”. As such, they have fewer legal protections than the seafarers they work Poor safety standards on alongside. This, compounded by the competitive commercial environment in which the private maritime security companies floating armoury vessel operate, reduces the incentive to ensure high safety and welfare standards. CHIRP wonders whether there is an Initial report expectation that, because of their military backgrounds, A security guard working aboard a 50-year-old and 50m armed guards will be prepared to tolerate poor conditions LOA floating armoury vessel reported unsanitary and unsafe and to accept increased safety risks? conditions on board. These vessels provide privately CHIRP intends to discuss the issues raised in this report contracted armed security personnel to commercial ships with both the International Transport Workers Federation for armed protection while they transit areas of high risk. (ITF) and the International Labour Organization (ILO) Despite having a maximum capacity of 60 people, the because of the obvious safety risks highlighted. floating armoury reportedly carries up to 150, and many are forced to sleep on the upper deck even in rough weather, due to the lack of available bunks. The water in the showers is rusty, CHIRP intends to discuss this issue with there are cockroaches in the food, the electrical wiring is in a both the International Transport Workers poor state of repair and water drips from the cable connections, creating a dangerous fire risk. The lack of an isolation area for Federation (ITF) and the International Labour Covid cases caused the virus to spread rapidly on board. Organization (ILO) Transfers onto and off merchant vessels are made using an inflatable boat, and embarkation is ordinarily by ships’ pilot ladders. Transfers take place even in high sea states Human Factors relating to this report (6-8m waves) because the merchant ships cannot afford to Fit for purpose – Is the existing international regulatory be delayed, so these transfers are especially risky. environment in which private maritime security companies The reporter stated that the floating armoury is operate fit for purpose? The UNDOC report suggests that resupplied with food and water at sea: it often spends many this should be reviewed. months in international waters and rarely visits port due to the difficulties of entering territorial waters with guns and Culture – Judging by the vessel’s condition, and its safety ammunition on board. and welfare standards, there were many longstanding Because of this, garbage is thrown into the sea, breaches of IMO, ILO and Marpol regulations, which both contravening Marpol regulations. The hull was recently the Master and the company employing the guards must punctured, and repaired using quick-drying cement, but is have known about. This incident raises questions about unlikely to be properly repaired for many months until the culture: are commercial pressure and profit being pursued vessel next visits port. to the detriment of the guards’ and crew’s safety and The reporter approached CHIRP because there was welfare? Is this allowed to happen because the guards no-one else that could help them. The reporter stated operate on pseudo-military lines and are thus expected to

www.chirpmaritime.org that the floating armoury vessels and the private maritime be task-oriented and tolerant of greater hardships and risks security companies who employ the guards vary in quality. to achieve their aims? Because there is very little access to the internet on the armoury vessels, they could only contact CHIRP once Alerting – The reporter contacted CHIRP because they embarked on a merchant ship. feared that they would lose their job if they raised this issue through their company or with the Master. Likewise, CHIRP Comment the Master initially said that he wanted to assist CHIRP in CHIRP raised these concerns with the Master and owners resolving the issue but ultimately this did not happen – was of the floating armoury vessel, who initially said that they this for fear of speaking up? Are you in a similar position – if

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so, CHIRP is interested in hearing from you? Similarly, the ITF Culture – The wrong knot was used repeatedly but

and ISWAN can assist with employment issues and welfare. appears not to have been challenged. This is known as a ‘normalisation of deviance’ which indicates that there is a Local practices – The report highlighted several poor culture either of acceptance of poor practice or a lack of local practices such as throwing rubbish overboard empowerment to challenge obvious safety deficiencies. and using the inflatable boat to transfer people to other vessels in high sea states. The condition of the vessel Teamwork – A high-performing team is one where indicates that on board maintenance was similarly individuals are open to supportive and constructive inadequate. All these significantly increase the dangers challenges from other team-members. This ensures that to the safety of people on board and to the environment. standards are maintained (or even enhanced) and everyone The correct procedures should be documented in the learns from each other. vessel’s Safety Management System By contrast, members of poorly performing teams may not speak up either because they lack confidence (“Will I look silly if I’m wrong?”) or because they fear reprisals (“Will I get into trouble for speaking up?”) or because they don’t M1875 want to embarrass another team member (“I don’t want to get them into trouble”). As a result, opportunities to improve Poor choice of knot puts are missed and dangerous situations are created.

pilot in jeopardy Initial report M1877 While boarding a vessel at sea a pilot found that the combination ladder was affixed solely by overhand knots (see pictures) . These easily unravel if there is strain from the Fall from vertical quayside standing part of the rope, e.g., under the weight of a pilot as ladder has near-fatal they ascend or descend the ladder. This type of knot must never be used in the rigging of a pilot ladder or gangway. consequences CHIRP Comment Initial report The correct knot in these circumstances is either a round A fisher returned to their vessel with a guest in the late turn and two half hitches or a bowline. The rigging of a evening after they had met ashore. Both had drunk alcohol. gangway which is to be used as part of a combination It was low tide, and the vessel was approximately 6m below ladder arrangement is a task normally undertaken by the quay edge due to the tidal range in that port. 2-3 deck crew. It should then be inspected by the officer As they climbed down the vertical quayside ladder, the detailed to meet the pilot. guest fell off the ladder and hit the vessel’s hull before The repeated use of overhand knots in this case falling, injured, into the water. The sea temperature was indicates that either the officer did not correctly supervise approximately 10° C (50° F). and inspect, or that the crew have become desensitized to a deviance from standard procedures: the local practice on the ship or within the company for securing the pilot ladder rope with an overhand knot had become the accepted norm. Despite being incorrect there appears to be no culture of challenge by the crew or officers to secure the ropework with the correct knot.

The fisher was unable to recover the person in the water and entered the water himself in an attempt to keep the guest from drowning. A crew member from another fishing vessel moored nearby heard the commotion and managed to recover the injured person and the crew member from the water back Human Factors relating to this report onto the deck of the fishing vessel. Due to the effects of the Capability – Knowing which knot to use in a particular cold water and the injuries, the guest was unresponsive and situation is an essential seamanship skill that every deck not breathing. hand should learn at the start of their career, but in this The port authority’s security team called an ambulance incident, it appears that neither the crewmember who tied and commenced CPR on the casualty until the emergency the knot nor those working with them recognised that this services arrived, but it took over an hour to lift them from was the wrong knot to use. Is this a training gap? the vessel and up the 6m to the quayside